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Clinical Finding

Syndrome

Common Causes

Pareses

Paresis of horizontal gaze in one direction

Conjugate horizontal gaze palsy

Lesion in the ipsilateral pontine horizontal gaze center or in the contralateral frontal cortex

Paresis of horizontal gaze in both directions

Complete (bilateral) horizontal gaze palsy

Wernicke encephalopathy

Large bilateral pontine lesion affecting both horizontal gaze centers

Bilateral paresis of all horizontal eye movements except for abduction of the eye contralateral to the lesion; convergence unaffected

One-and-a-half syndrome

Lesion in the medial longitudinal fasciculus and ipsilateral pontine horizontal gaze center

Unilateral or bilateral paresis of eye adduction in horizontal lateral gaze but not in convergence

Internuclear ophthalmoplegia

Lesion in the medial longitudinal fasciculus

Bilateral paresis of upward eye movement with dilated pupils, loss of the pupillary light response despite preservation of pupillary accommodation and constriction with convergence, downward gaze preference, and downbeating nystagmus

Parinaud syndrome (a type of conjugate vertical gaze palsy)

Pineal tumor

Dorsal midbrain infarct

Bilateral paresis of downward eye movements

Conjugate downward gaze palsy

Progressive supranuclear palsy

Unilateral eye deviation (resting position is down and out); unilateral paresis of eye adduction, elevation, and depression; ptosis; and often a dilated pupil

3rd cranial nerve palsy

Aneurysms

Oculomotor nerve or midbrain microvascular disease (diabetes and hypertension)

Trauma

Transtentorial herniation

Unilateral paresis of downward and inward (nasal) eye movement, which may be subtle, causing symptoms (difficulty looking down and inward)

Head tilt sign (patient tilts the head to the side opposite the affected eye)

4th cranial nerve palsy

Idiopathic

Head trauma

Ischemia

Congenital

Unilateral paresis of eye abduction

6th cranial nerve palsy

Idiopathic

Increased intracranial pressure

Microvascular disease secondary to diabetes or hypertension

Multiple sclerosis

Trauma

Tumors

Vasculitis

Skew deviation (vertical misalignment of the eyes)

Partial and unequal involvement of 3rd cranial nerve nuclei, vertical gaze center, or median longitudinal fasciculus

Brain stem lesion anywhere from midbrain to medulla

Weakness or restriction of all extraocular muscles

External ophthalmoplegia

Dysfunction of eye muscles or of neuromuscular junction

Usually caused by the following:

Involuntary or abnormal movements

Rhythmic involuntary movements, usually bilateral

Nystagmus

Many causes:

  • Vestibular disorders (eg, Meniere disease, vestibular neuronitis)

  • Multiple sclerosis

  • Head trauma

  • Drugs (eg, antiseizure drugs, anxiolytics, and sedatives)

Fast downward jerk and slow upward return to midposition

Ocular bobbing

Extensive pontine destruction or dysfunction

Gaze overshoot followed by several oscillations

Ocular dysmetria

Cerebellar pathway disorders

Burst of rapid horizontal oscillations about a point of fixation

Ocular flutter

Many causes:

  • Postanoxic encephalopathy

  • Occult neuroblastoma

  • Paraneoplastic effects

  • Ataxia-telangiectasia

  • Viral encephalitis

  • Toxic effects of drugs

Rapid, conjugate, multidirectional, chaotic movements, often with widespread myoclonus

Opsoclonus

Many causes (same as for ocular flutter, above)