Explain internuclearophtholmoplegia in a simple way

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Here is a simple, clear explanation of internuclear ophthalmoplegia (INO):

Internuclear Ophthalmoplegia (INO) - Simply Explained

The One-Line Version

INO is a brainstem problem where one eye cannot move inward (adduct) when you look to the side, while the other eye moves outward normally but with a shaky wobble (nystagmus).

The "Highway" Analogy

Think of your two eyes as two cars that always need to travel together as a team. For them to move left or right in sync, there is a communication highway in the brainstem called the Medial Longitudinal Fasciculus (MLF). This highway connects the nerve nuclei that control the two eyes.

In INO, this highway is damaged on one side. So when you try to look to the right:

The right eye moves out just fine
But the left eye (which needs the MLF signal to move inward) gets stuck - it can't fully turn in
The right eye also starts wobbling (nystagmus) because it's getting an overcompensating signal

Left INO - Panel A shows eyes straight ahead, Panel B shows limited left adduction on right gaze, Panel C shows normal left abduction on left gaze

Left INO: (A) Eyes look straight - normal. (B) Looking right - the left eye can't fully move inward. (C) Looking left - left eye moves outward normally.

Key Facts in Simple Terms

Feature	What it means simply
Lesion site	Damage to the MLF (a nerve tract in the brainstem)
Which side is "affected"	Named for the eye that can't adduct (move inward)
Classic sign	Weak adduction + nystagmus in the OTHER eye
Convergence	Usually preserved (both eyes can still cross for near vision)
Symptoms	Double vision, blurry vision - but surprisingly many patients feel nothing!

Who Gets It?

Young people → Most likely Multiple Sclerosis (MS). Bilateral INO in a young adult is nearly diagnostic of MS.
Older people → Most likely a brainstem stroke
Roughly: 1/3 stroke, 1/3 MS, 1/3 other causes (trauma, tumors, infections)

A Special Variant: "One-and-a-Half Syndrome"

If the lesion also destroys the horizontal gaze center on the same side as the MLF damage, you get one-and-a-half syndrome:

The affected side can't look left or right (the "one" - a full gaze palsy to that side)
The other eye also can't adduct (the "half" - INO)
The only eye movement left is the contralateral eye abducting outward

Diagnosis & Treatment

MRI of the brainstem is the key investigation
Rule out mimics: myasthenia gravis (variable weakness, ptosis), thyroid eye disease, orbital tumor
A quick bedside clue: have the patient make a rapid eye movement - the adducting eye will be slower than normal even if it looks full
Treatment targets the underlying cause (MS treatment, stroke management). Persistent double vision can sometimes be treated with strabismus surgery.

Sources: Bradley and Daroff's Neurology in Clinical Practice; Kanski's Clinical Ophthalmology 10th Ed.; Wills Eye Manual

Create a diagnostic flowchart for eye movement disorders

Finding Sources

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Finding Sources

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Running Command

ls /home/daytona/workspace/ 2>/dev/null || echo "empty"

Running Command

mkdir -p /home/daytona/workspace/eye-flowchart && python3 -c "import matplotlib;…

Writing File

~/eye-flowchart/flowchart.py

import matplotlib
matplotlib.use('Agg')
import matplotlib.pyplot as plt
import matplotlib.patches as mpatches
from matplotlib.patches import FancyBboxPatch, FancyArrowPatch

fig, ax = plt.subplots(figsize=(22, 32))
ax.set_xlim(0, 22)
ax.set_ylim(0, 32)
ax.axis('off')
fig.patch.set_facecolor('#F0F4F8')

# ─── Color palette ───────────────────────────────────────────────────────────
C_START   = '#1A1A2E'   # deep navy  - start node
C_QUES    = '#16213E'   # dark blue  - decision diamonds
C_CAT1    = '#0F3460'   # medium blue - category boxes
C_MONO    = '#533483'   # purple     - monocular
C_BINO    = '#E94560'   # red        - binocular / serious
C_DIAG    = '#1A7431'   # green      - diagnosis boxes
C_INV     = '#B8621A'   # orange     - investigation boxes
C_TEXT    = 'white'
C_ARROW   = '#2C3E50'
C_BG      = '#F0F4F8'

def box(ax, x, y, w, h, text, color, fontsize=9, text_color='white', style='round,pad=0.1', alpha=1.0, bold=False):
    fancy = FancyBboxPatch((x - w/2, y - h/2), w, h,
                           boxstyle=style,
                           linewidth=1.2, edgecolor='white',
                           facecolor=color, alpha=alpha, zorder=3)
    ax.add_patch(fancy)
    weight = 'bold' if bold else 'normal'
    ax.text(x, y, text, ha='center', va='center', fontsize=fontsize,
            color=text_color, zorder=4, weight=weight,
            wrap=True, multialignment='center',
            fontfamily='DejaVu Sans')

def diamond(ax, x, y, w, h, text, color, fontsize=8.5):
    dx, dy = w/2, h/2
    xs = [x,      x+dx,  x,      x-dx,  x]
    ys = [y+dy,   y,     y-dy,   y,     y+dy]
    ax.fill(xs, ys, color=color, zorder=3, alpha=0.95)
    ax.plot(xs, ys, color='white', lw=1.2, zorder=4)
    ax.text(x, y, text, ha='center', va='center', fontsize=fontsize,
            color='white', zorder=5, weight='bold', multialignment='center')

def arrow(ax, x1, y1, x2, y2, label='', color=C_ARROW, lw=1.5):
    ax.annotate('', xy=(x2, y2), xytext=(x1, y1),
                arrowprops=dict(arrowstyle='->', color=color,
                                lw=lw, connectionstyle='arc3,rad=0.0'),
                zorder=2)
    if label:
        mx, my = (x1+x2)/2, (y1+y2)/2
        ax.text(mx+0.15, my, label, fontsize=7.5, color=color, zorder=5,
                va='center', style='italic')

def harrow(ax, x1, y1, x2, y2, label='', color=C_ARROW, lw=1.5):
    # Horizontal then vertical connector
    ax.annotate('', xy=(x2, y2), xytext=(x1, y1),
                arrowprops=dict(arrowstyle='->', color=color, lw=lw,
                                connectionstyle='angle,angleA=0,angleB=90'),
                zorder=2)
    if label:
        ax.text((x1+x2)/2, (y1+y2)/2 + 0.15, label, fontsize=7.5,
                color=color, ha='center', zorder=5, style='italic')

# ══════════════════════════════════════════════════════════════════════
# TITLE
# ══════════════════════════════════════════════════════════════════════
ax.text(11, 31.3, 'Diagnostic Flowchart: Eye Movement Disorders',
        ha='center', va='center', fontsize=16, weight='bold',
        color=C_START, fontfamily='DejaVu Sans')
ax.text(11, 30.85, 'Based on Bradley & Daroff\'s Neurology | Kanski\'s Clinical Ophthalmology | Wills Eye Manual',
        ha='center', va='center', fontsize=8, color='#666666')

# ══════════════════════════════════════════════════════════════════════
# NODE 1 — Start
# ══════════════════════════════════════════════════════════════════════
box(ax, 11, 30.2, 5.5, 0.7,
    'PATIENT PRESENTS WITH\nEYE MOVEMENT COMPLAINT',
    C_START, fontsize=10, bold=True)

arrow(ax, 11, 29.85, 11, 29.25)

# ══════════════════════════════════════════════════════════════════════
# Q1 — Diplopia?
# ══════════════════════════════════════════════════════════════════════
diamond(ax, 11, 28.85, 4.2, 0.8,
        'Is there DIPLOPIA\n(double vision)?', C_QUES)

# YES → down
arrow(ax, 11, 28.45, 11, 27.8, 'YES')

# NO → right branch (nystagmus / oscillopsia / gaze palsy)
harrow(ax, 13.1, 28.85, 17.5, 28.85, '')
ax.text(15.3, 28.95, 'NO', fontsize=7.5, color=C_ARROW, ha='center', style='italic')
box(ax, 17.5, 28.85, 3.8, 0.7,
    'OTHER: Nystagmus,\nOscillopsia, Gaze Palsy',
    C_CAT1, fontsize=8.5)
arrow(ax, 17.5, 28.5, 17.5, 27.8)

# ──────────────────────────────────────────────────────────────────────
# NYSTAGMUS branch (right side)
# ──────────────────────────────────────────────────────────────────────
diamond(ax, 17.5, 27.4, 3.8, 0.7,
        'Type of\nabnormal movement?', C_QUES, fontsize=8)

# Nystagmus down
arrow(ax, 17.5, 27.05, 17.5, 26.45, 'Nystagmus')
box(ax, 17.5, 26.1, 3.8, 0.65,
    'Central vs Peripheral?\n(direction, fixation, onset)',
    C_CAT1, fontsize=8)
arrow(ax, 17.5, 25.78, 17.5, 25.2)
box(ax, 17.5, 24.9, 3.8, 0.55,
    'Peripheral: BPPV, Labyrinthitis\nCentral: Brainstem/Cerebellum',
    C_DIAG, fontsize=7.5)

# Gaze palsy → left
harrow(ax, 15.6, 27.4, 13.8, 27.4, '')
ax.text(14.7, 27.5, 'Gaze Palsy', fontsize=7, color=C_ARROW, ha='center', style='italic')
box(ax, 13, 27.4, 2.8, 0.55,
    'See: Gaze Palsy\nSection Below',
    C_CAT1, fontsize=7.5)


# ══════════════════════════════════════════════════════════════════════
# Q2 — Monocular or Binocular?
# ══════════════════════════════════════════════════════════════════════
diamond(ax, 11, 27.4, 4.2, 0.7,
        'Cover one eye —\nDiplopia RESOLVES?', C_QUES)

# YES (binocular) → down
arrow(ax, 11, 27.05, 11, 26.45, 'YES → Binocular')

# NO (monocular) → left
harrow(ax, 8.9, 27.4, 5.5, 27.4, '')
ax.text(7.2, 27.55, 'NO → Monocular', fontsize=7.5, color=C_ARROW, ha='center', style='italic')
box(ax, 5.5, 27.4, 3.2, 0.55,
    'MONOCULAR DIPLOPIA\nRefractive error, Cataract,\nCorneal irregularity',
    C_MONO, fontsize=7.5)
arrow(ax, 5.5, 27.13, 5.5, 26.55)
box(ax, 5.5, 26.25, 3.2, 0.55,
    'Refer Ophthalmology\nRefraction / Slit Lamp',
    C_INV, fontsize=7.5)

# ══════════════════════════════════════════════════════════════════════
# Q3 — Painful?
# ══════════════════════════════════════════════════════════════════════
diamond(ax, 11, 26.1, 4.2, 0.65,
        'Is the diplopia\nPAINFUL?', C_QUES)

# YES → right (painful binocular)
harrow(ax, 13.1, 26.1, 15.5, 26.1, '')
ax.text(14.3, 26.22, 'YES', fontsize=7.5, color=C_BINO, ha='center', style='italic')
box(ax, 15.5, 26.1, 2.8, 0.55,
    'PAINFUL DIPLOPIA\n⚠ Red Flag',
    C_BINO, fontsize=8, bold=True)
arrow(ax, 15.5, 25.83, 15.5, 25.35)
box(ax, 15.5, 25.05, 2.8, 0.55,
    'Consider:\nCavernous Sinus Thrombosis\nPCA Aneurysm\nTolosa-Hunt Syndrome\nOrbital Cellulitis',
    C_BINO, fontsize=7)
arrow(ax, 15.5, 24.78, 15.5, 24.25)
box(ax, 15.5, 24.0, 2.8, 0.45,
    'URGENT: MRI/MRA Brain\n+ CTA if aneurysm suspected',
    C_INV, fontsize=7.5)

# NO → down (painless binocular)
arrow(ax, 11, 25.78, 11, 25.2, 'NO')

# ══════════════════════════════════════════════════════════════════════
# Q4 — Which direction is diplopia worse?
# ══════════════════════════════════════════════════════════════════════
diamond(ax, 11, 24.85, 4.4, 0.65,
        'Direction of\nMAXIMAL diplopia?', C_QUES, fontsize=8.5)

# Horizontal → left
harrow(ax, 8.8, 24.85, 6.2, 24.85, '')
ax.text(7.5, 25.0, 'Horizontal', fontsize=7.5, color=C_ARROW, ha='center', style='italic')

# Vertical → down
arrow(ax, 11, 24.52, 11, 23.95, 'Vertical')

# Oblique / mixed → right
harrow(ax, 13.2, 24.85, 15.0, 24.85, '')
ax.text(14.1, 25.0, 'Oblique', fontsize=7.5, color=C_ARROW, ha='center', style='italic')

# ══════════════════════════════════════════════════════════════════════
# HORIZONTAL BRANCH (left side)
# ══════════════════════════════════════════════════════════════════════
box(ax, 6.2, 24.85, 3.2, 0.55,
    'HORIZONTAL DIPLOPIA',
    C_CAT1, fontsize=8.5, bold=True)
arrow(ax, 6.2, 24.57, 6.2, 24.0)

diamond(ax, 6.2, 23.65, 3.2, 0.65,
        'Adduction\ndefect?', C_QUES, fontsize=8)

# Yes adduction → left = INO
harrow(ax, 4.6, 23.65, 3.0, 23.65, '')
ax.text(3.8, 23.8, 'YES', fontsize=7, color=C_ARROW, style='italic')
box(ax, 3.0, 23.65, 2.4, 0.55,
    'INO\n(MLF Lesion)\nMS / Stroke',
    C_DIAG, fontsize=7.5)
arrow(ax, 3.0, 23.38, 3.0, 22.85)
box(ax, 3.0, 22.6, 2.4, 0.45,
    'MRI Brain\n(thin brainstem cuts)',
    C_INV, fontsize=7.5)

# No adduction → down = CN VI
arrow(ax, 6.2, 23.33, 6.2, 22.8, 'NO')
box(ax, 6.2, 22.5, 3.2, 0.55,
    'Abduction defect?\n→ CN VI (Abducens) Palsy\nLateral rectus weakness',
    C_DIAG, fontsize=7.5)
arrow(ax, 6.2, 22.23, 6.2, 21.7)
box(ax, 6.2, 21.45, 3.2, 0.5,
    'MRI Brain/Orbit\nRule out raised ICP\nRule out Wernicke\'s',
    C_INV, fontsize=7.5)

# ══════════════════════════════════════════════════════════════════════
# VERTICAL BRANCH (center-down)
# ══════════════════════════════════════════════════════════════════════
box(ax, 11, 23.65, 3.6, 0.55,
    'VERTICAL DIPLOPIA',
    C_CAT1, fontsize=8.5, bold=True)
arrow(ax, 11, 23.38, 11, 22.8)

diamond(ax, 11, 22.45, 3.6, 0.65,
        'Head tilt test\n(3-step test)?', C_QUES, fontsize=8)

# Positive → CN IV
harrow(ax, 12.8, 22.45, 14.8, 22.45, '')
ax.text(13.8, 22.6, 'Positive', fontsize=7, color=C_ARROW, style='italic')
box(ax, 14.8, 22.45, 2.8, 0.55,
    'CN IV (Trochlear) Palsy\nSuperior oblique weak\nHead tilt to opposite side',
    C_DIAG, fontsize=7.5)
arrow(ax, 14.8, 22.18, 14.8, 21.65)
box(ax, 14.8, 21.4, 2.8, 0.5,
    'MRI / Check BP\nRule out diabetic\nneuropathy, trauma',
    C_INV, fontsize=7.5)

# Negative → other
arrow(ax, 11, 22.13, 11, 21.6, 'Negative')
box(ax, 11, 21.3, 3.6, 0.55,
    'Skew Deviation\nMyasthenia Gravis\nThyroid Eye Disease',
    C_DIAG, fontsize=7.5)
arrow(ax, 11, 21.03, 11, 20.5)
box(ax, 11, 20.25, 3.6, 0.5,
    'AChR Ab / Tensilon test\nTFTs / Orbital imaging\nMRI Brainstem',
    C_INV, fontsize=7.5)

# ══════════════════════════════════════════════════════════════════════
# OBLIQUE / MIXED BRANCH (right side, down)
# ══════════════════════════════════════════════════════════════════════
box(ax, 15.0, 24.85, 2.8, 0.55,
    'OBLIQUE / MIXED\nDIPLOPIA',
    C_CAT1, fontsize=8.5, bold=True)
arrow(ax, 15.0, 24.57, 15.0, 24.05)
box(ax, 15.0, 23.75, 2.8, 0.55,
    'CN III Palsy?\nPtosis + dilated pupil\n+ "down and out" eye',
    C_DIAG, fontsize=7.5)
arrow(ax, 15.0, 23.48, 15.0, 22.95)
diamond(ax, 15.0, 22.6, 2.8, 0.65,
        'Pupil\ninvolved?', C_QUES, fontsize=8)
# YES pupil → aneurysm
harrow(ax, 16.4, 22.6, 18.0, 22.6, '')
ax.text(17.2, 22.73, 'YES', fontsize=7, color=C_BINO, style='italic')
box(ax, 18.0, 22.6, 2.5, 0.55,
    '⚠ URGENT\nPCA Aneurysm\nuntil proven otherwise',
    C_BINO, fontsize=7.5, bold=True)
arrow(ax, 18.0, 22.33, 18.0, 21.8)
box(ax, 18.0, 21.55, 2.5, 0.5,
    'CTA / MRA BRAIN\nNeurosurgery consult',
    C_INV, fontsize=7.5)

# NO pupil → medical CN III
arrow(ax, 15.0, 22.28, 15.0, 21.75, 'NO')
box(ax, 15.0, 21.5, 2.8, 0.5,
    'Medical CN III\nDiabetes, HTN\nSpare pupil',
    C_DIAG, fontsize=7.5)
arrow(ax, 15.0, 21.25, 15.0, 20.75)
box(ax, 15.0, 20.5, 2.8, 0.5,
    'HbA1c / BP control\nMRI if no improvement\nin 3 months',
    C_INV, fontsize=7.5)

# ══════════════════════════════════════════════════════════════════════
# GAZE PALSY SECTION (bottom center)
# ══════════════════════════════════════════════════════════════════════
box(ax, 11, 19.4, 6.0, 0.65,
    'GAZE PALSY (Conjugate gaze disorder — no diplopia)',
    C_START, fontsize=9, bold=True)

# connect from "See: Gaze Palsy Section Below"
arrow(ax, 13.0, 27.13, 13.0, 25.0)
harrow(ax, 13.0, 25.0, 11.0, 19.73)

diamond(ax, 11, 18.75, 5.0, 0.7,
        'Direction of gaze palsy?', C_QUES, fontsize=9)

# Horizontal left
harrow(ax, 8.5, 18.75, 5.5, 18.75, '')
ax.text(7.0, 18.9, 'Horizontal', fontsize=7.5, color=C_ARROW, ha='center', style='italic')

# Vertical down
arrow(ax, 11, 18.4, 11, 17.85, 'Vertical')

# One-and-half → right
harrow(ax, 13.5, 18.75, 16.5, 18.75, '')
ax.text(15.0, 18.9, 'One-and-half\nsyndrome', fontsize=7, color=C_ARROW, ha='center', style='italic')

# ── Horizontal gaze palsy
box(ax, 5.5, 18.75, 3.2, 0.6,
    'HORIZONTAL GAZE PALSY',
    C_CAT1, fontsize=8, bold=True)
arrow(ax, 5.5, 18.45, 5.5, 17.9)
box(ax, 5.5, 17.6, 3.4, 0.6,
    'Frontal (FEF) Lesion:\nEyes deviate TOWARD lesion\n(ipsilateral gaze preference)',
    C_DIAG, fontsize=7.5)
arrow(ax, 5.5, 17.3, 5.5, 16.8)
box(ax, 5.5, 16.55, 3.4, 0.45,
    'Pontine (PPRF) Lesion:\nEyes deviate AWAY from lesion\n(contralateral gaze preference)',
    C_DIAG, fontsize=7.5)
arrow(ax, 5.5, 16.33, 5.5, 15.85)
box(ax, 5.5, 15.6, 3.0, 0.45,
    'MRI Brain\n(Stroke / MS / Tumor)',
    C_INV, fontsize=7.5)

# ── Vertical gaze palsy
box(ax, 11, 17.55, 3.6, 0.6,
    'VERTICAL GAZE PALSY',
    C_CAT1, fontsize=8, bold=True)
arrow(ax, 11, 17.25, 11, 16.7)
box(ax, 11, 16.4, 3.8, 0.65,
    'Parinaud Syndrome\n(Dorsal Midbrain)\nUpgaze palsy + convergence-\nretraction nystagmus + lid lag',
    C_DIAG, fontsize=7.5)
arrow(ax, 11, 16.08, 11, 15.6)
box(ax, 11, 15.35, 3.8, 0.45,
    'MRI Midbrain\n(Pineal tumor, Hydrocephalus, MS)',
    C_INV, fontsize=7.5)

# ── One-and-half syndrome
box(ax, 16.5, 18.75, 3.0, 0.6,
    'ONE-AND-HALF\nSYNDROME',
    C_CAT1, fontsize=8, bold=True)
arrow(ax, 16.5, 18.45, 16.5, 17.9)
box(ax, 16.5, 17.6, 3.2, 0.65,
    'Ipsilateral gaze palsy\n+ INO\nOnly: contralateral eye\nabducts (+ nystagmus)',
    C_DIAG, fontsize=7.5)
arrow(ax, 16.5, 17.28, 16.5, 16.8)
box(ax, 16.5, 16.55, 3.0, 0.45,
    'Pontine lesion (PPRF + MLF)\nMRI brainstem\nMS / Stroke',
    C_INV, fontsize=7.5)

# ══════════════════════════════════════════════════════════════════════
# LEGEND
# ══════════════════════════════════════════════════════════════════════
legend_items = [
    (C_QUES,  'Decision Point'),
    (C_CAT1,  'Category / Pathway'),
    (C_DIAG,  'Diagnosis'),
    (C_INV,   'Investigation'),
    (C_MONO,  'Monocular cause'),
    (C_BINO,  'Urgent / Red Flag'),
]
lx, ly = 0.6, 15.5
ax.text(lx, ly, 'LEGEND', fontsize=8, weight='bold', color=C_START)
for i, (col, label) in enumerate(legend_items):
    ry = ly - 0.5 - i * 0.5
    rect = FancyBboxPatch((lx, ry - 0.17), 0.5, 0.35,
                          boxstyle='round,pad=0.05',
                          facecolor=col, edgecolor='white', lw=0.8, zorder=3)
    ax.add_patch(rect)
    ax.text(lx + 0.65, ry, label, fontsize=7.5, va='center', color=C_START)

plt.tight_layout(pad=0.5)
plt.savefig('/home/daytona/workspace/eye-flowchart/eye_movement_flowchart.png',
            dpi=180, bbox_inches='tight', facecolor=C_BG)
print("Done")

Running Command

cd /home/daytona/workspace/eye-flowchart && python3 flowchart.py 2>&1

Reading File

The file generated successfully (it's just too large for preview here). Here is your diagnostic flowchart:

eye movement flowchart

Image · PNG

Here's what the flowchart covers, structured as a clinical decision tree:

Flowchart Structure Summary

Starting Point: Patient with Eye Movement Complaint

Step 1 - Is there diplopia (double vision)?

NO → Diverts to: Nystagmus / Oscillopsia / Gaze Palsy branch
YES → Continue

Step 2 - Monocular or Binocular? (Cover one eye)

Monocular (diplopia persists with one eye covered) → Refractive error, Cataract, Corneal pathology → Ophthalmology referral
Binocular (diplopia resolves on covering) → Continue

Step 3 - Painful?

YES → Red Flag: Cavernous sinus thrombosis, PCA aneurysm, Tolosa-Hunt, Orbital cellulitis → URGENT MRI/MRA
NO → Continue

Step 4 - Direction of maximal diplopia?

Direction	Likely Lesion	Key Clue
Horizontal	CN VI palsy (abduction defect) or INO (adduction defect)	INO = adduction weak + nystagmus in other eye
Vertical	CN IV palsy (trochlear)	Park's 3-step test positive; head tilt
Oblique/Mixed	CN III palsy	Ptosis + dilated pupil + "down and out" eye

CN III - Critical sub-question: Is the pupil involved?

YES → Urgent: Posterior communicating artery aneurysm → CTA/MRA + neurosurgery
NO → Medical CN III (diabetes, hypertension) → HbA1c, BP control, monitor

Gaze Palsy Branch

Type	Lesion	Features
Horizontal	Frontal (FEF) = eyes toward lesion; Pontine (PPRF) = eyes away from lesion
Vertical	Parinaud syndrome (dorsal midbrain)	Upgaze palsy + convergence-retraction nystagmus
One-and-half	PPRF + MLF (same side)	Only contralateral abduction preserved

Sources: Bradley & Daroff's Neurology in Clinical Practice; Kanski's Clinical Ophthalmology 10th Ed.; Wills Eye Manual

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