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Explain internuclear opthalmoplegia

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Internuclear Ophthalmoplegia (INO)

Definition

Internuclear ophthalmoplegia is a disorder of conjugate horizontal eye movement caused by a lesion in the medial longitudinal fasciculus (MLF) - the brainstem tract that coordinates communication between the abducens nucleus (CN VI, in the pons) and the contralateral oculomotor nucleus (CN III, in the midbrain).

Bradley and Daroff's Neurology in Clinical Practice, p. 257
Kanski's Clinical Ophthalmology, 10th ed., p. 836

Anatomy and Pathophysiology

The Normal Horizontal Gaze Circuit

For the eyes to look right, for example:

The right PPRF (paramedian pontine reticular formation) fires the right abducens nucleus (CN VI)
The right CN VI does two things simultaneously:
- Drives the right lateral rectus (right eye abducts)
- Sends an internuclear signal up the left MLF to the left CN III nucleus - which drives the left medial rectus (left eye adducts)
Both eyes move right together - conjugate gaze

What Goes Wrong in INO

A lesion of the MLF on one side breaks this internuclear connection. The ipsilateral medial rectus no longer receives its signal during horizontal gaze away from the lesion side.

Result:

The ipsilateral eye fails to adduct (or adducts slowly/incompletely) when attempting contralateral gaze
The contralateral eye abducts normally but shows nystagmus (ataxic/dissociated nystagmus) - it "overshoots" because it's not getting the normal dampening signal

The side of the lesion is named for the side of the adduction deficit (not the nystagmus side).

Bradley and Daroff's, p. 902
Scott-Brown's Otorhinolaryngology, p. 3228

Classic Clinical Signs

Sign	Detail
Adduction deficit	Ipsilateral eye fails/slows to adduct on contralateral gaze
Abducting nystagmus	Contralateral (abducting) eye shows horizontal nystagmus
Primary position	Eyes often straight (no deviation at rest)
Convergence	Intact if lesion is anterior/discrete; impaired if posterior or extensive
Vertical pursuit	May be abnormal (MLF also carries vertical VOR signals)
Skew deviation	May occur - vertical ocular misalignment from otolith pathway damage

Kanski's Clinical Ophthalmology, p. 836
Bradley and Daroff's, p. 3025-3029

Clinical Photographs

Left INO - from Kanski's Clinical Ophthalmology:

Left INO: (A) Straight in primary position; (B) limitation of left adduction on right gaze; (C) normal left abduction on left gaze

Fig. 19.83: Left INO. (A) Straight eyes in primary position. (B) Left eye fails to adduct on right gaze. (C) Normal left abduction preserved.

Bilateral INO:

Fig. 19.84: Bilateral INO. (A) Left adduction limited on right gaze. (B) Right adduction limited on left gaze. (C) Convergence is preserved.

Unilateral vs. Bilateral INO

Unilateral INO

Defective adduction of the eye on the side of the lesion
Gaze toward the side of the lesion is normal
Most common causes: stroke (older patients), multiple sclerosis (younger patients)
Demyelinating and small vascular lesions are the most common causes when unaccompanied by other brainstem signs

Bilateral INO

Both eyes fail to adduct in opposite directions
Limitation of left adduction on right gaze AND limitation of right adduction on left gaze
Bilateral INO in a young adult is virtually diagnostic of MS (Adams & Victor's, p. 261)
Convergence may be intact or impaired
A rostral midbrain lesion can produce WEBINO (Wall-Eyed Bilateral INO) - bilateral exotropia with convergence deficit
Goldman-Cecil Medicine, p. 1405
Adams and Victor's Principles of Neurology, 12th ed.

Causes

Category	Specific Causes
Demyelination	Multiple sclerosis (most common in young adults, especially bilateral)
Vascular	Brainstem stroke (most common in older adults), vertebral artery dissection, small vessel infarction
Structural	Tumour, brainstem compression (subdural haematoma, transtentorial herniation, cerebellar mass)
Inflammatory/Infectious	Vasculitis, infections
Traumatic	Head trauma
Iatrogenic	Post-surgical
Mimics	Myasthenia gravis (MG), Guillain-Barre syndrome, Miller Fisher syndrome

One large series found approximately 1/3 stroke, 1/3 MS, 1/3 other causes (Keane, 2005) - cited in Bradley and Daroff's, p. 3033

Symptoms

Surprisingly, most patients with INO are asymptomatic. When symptoms occur:

Diplopia - horizontal (from medial rectus paresis) or vertical (from skew deviation)
Oscillopsia - one image appears to jiggle
Blurred vision
Bradley and Daroff's, p. 3027

Variants and Related Syndromes

WEBINO (Wall-Eyed Bilateral INO)

Rostral midbrain lesion producing bilateral INO + convergence deficit
Results in bilateral exotropia (wall-eyed) with abducting nystagmus bilaterally

One-and-a-Half Syndrome

Combined lesion of the PPRF (or abducens nucleus) + MLF on the same side
Results in: ipsilateral gaze palsy (the "one") + ipsilateral INO (the "half")
Only preserved movement: abduction of the contralateral eye (with nystagmus)
Kanski's, p. 836

Eight-and-a-Half Syndrome

One-and-a-half syndrome + ipsilateral facial nerve (CN VII) palsy
Due to dorsal tegmental caudal pontine lesion involving PPRF/abducens nucleus + MLF + CN VII fascicles
Localization in Clinical Neurology, 8e

Differentiating INO from Mimics

Condition	Convergence	Other features
True INO (MLF lesion)	Intact (if anterior)	Nystagmus in abducting eye; no ptosis
Partial CN III palsy	Impaired	May have ptosis, pupil changes
Myasthenia gravis	Variable, fatigable	Ptosis, positive Tensilon test, fatigability
Thyroid eye disease	Normal	Proptosis, lid retraction, restriction pattern
Strabismus	Normal	Long history, no nystagmus

The key distinguishing feature: intact convergence in an isolated MLF lesion (the medial rectus works for convergence via a different pathway) but impaired adduction during horizontal gaze. - Bradley and Daroff's, p. 3033

Investigations

MRI brain (with thin-cut pontine sequences) - modality of choice; may show demyelinating plaque or infarct in the MLF. T2-weighted imaging can reveal hyperintense lesion in the MLF
If associated signs suggest MG, do acetylcholine receptor antibodies, Tensilon test
Vascular workup (CTA/MRA, vessel imaging) if stroke is suspected

Treatment

Treatment is directed at the underlying cause:

MS: disease-modifying therapy
Stroke: antiplatelet/anticoagulation, thrombolysis if acute
Strabismus surgery may be offered for persistent diplopia that doesn't resolve spontaneously

Most cases of INO improve partially or fully once the underlying cause is treated. Prism glasses can help with persistent diplopia in the interim.

Kanski's Clinical Ophthalmology, p. 836

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