Multiple Sclerosis Presenting with Bilateral Internuclear Ophthalmoplegia (INO)

  • An-Guor Wang


A 37-year-old male reported suffering with blurred vision OU for a long time. He was diagnosed with multiple sclerosis at a local hospital approximately 4 years ago. He had received methylprednisolone treatment, but dizziness persisted. He then visited our Neurology department complaining of dizziness and loss of balance for 8 months. He also cited experiencing blurry vision, motion and speech slowness, poor appetite, and hand tremors. Ophthalmic consultation reported a visual acuity of 6/20 in the right eye and 6/15 in the left. Moderate limitation of adduction was noted in both eyes (Fig. 34.1). Both eyes showed dissociated abducting nystagmus (Video 34.1). Slit lamp and fundoscopic examinations were normal. The visual field was full in both eyes. MR imaging of the brain showed multiple abnormal high signals on T2WI involving bilateral deep white matter, corpus callosum, occipital periventricular regions, and periaqueductal regions of the pons and medulla (Fig. 34.2). The patient also underwent a lumbar puncture with opening and closing pressures of 108 and 57 mmH2O, respectively. IgG index was 2.7. He also received thiamine treatment, but this treatment was not effective per the patient. He was discharged under the impression of multiple sclerosis.

Supplementary material

Video 34.1

(MOV 34060 kb)


  1. 1.
    Virgo JD, Plant GT. Internuclear ophthalmoplegia. Pract Neurol. 2017;17(2):149–53.CrossRefPubMedGoogle Scholar
  2. 2.
    Wu YT, Cafiero-Chin M, Marques C. Wall-eyed bilateral internuclear ophthalmoplegia: review of pathogenesis, diagnosis, prognosis and management. Clin Exp Optom. 2015;98(1):25–30.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Frohman TC, Galetta S, Fox R, Solomon D, Filippi M, Straumann D, Zee D, et al. Pearls & Oy-sters: the medial longitudinal fasciculus in ocular motor physiology. Neurology. 2008;70:e57–67.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Wong AME. Eye movement disorders. Oxford: Oxford University Press; 2008. p. 130–1.Google Scholar
  5. 5.
    Carpenter MB, Batton RR III. Abducens internuclear neurons and their role in conjugate horizontal gaze. J Comp Neurol. 1980;189(1):191–209.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Miller NR, Newman NJ. Walsh and hoyt’s clinical neuro-ophthalmology. Baltimore: Lippincott Williams & Wilkins; 2005.Google Scholar
  7. 7.
    Keane JR. Internuclear ophthalmoplegia: unusual causes in 114 of 410 patients. Arch Neurol. 2005;62:714–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Tsuda H, Ishikawa H, Matsunaga H, Mizutani T. A neuro-ophthalmological analysis in 80 cases of multiple sclerosis. Rinsho Shinkeigaku. 2004;44:513–21.PubMedGoogle Scholar
  9. 9.
    Ushio M, Iwasaki S, Chihara Y, Murofushi T. Walleyed bilateral internuclear ophthalmoplegia in a patient with progressive supranuclear palsy. J Neuroophthalmol. 2008;28:93–6.CrossRefPubMedGoogle Scholar
  10. 10.
    Fagúndez Vargas MA, Andrés Domingo ML, Calvo Arrabal MA. The WEBINO syndrome as presentation form of myasthenia gravis. Arch Soc Esp Oftalmol. 2000;75(7):485–8.PubMedPubMedCentralGoogle Scholar
  11. 11.
    Ito K, Mizutani J, Murofushi T, Mizuno M. Bilateral pseudo-internuclear ophthalmoplegia in myasthenia gravis. ORL J Otorhinolaryngol Relat Spec. 1997;59(2):122–6.CrossRefPubMedGoogle Scholar
  12. 12.
    Adams WE, Leavitt JA, Holmes JM. Strabismus surgery for internuclear ophthalmoplegia with exotropia in multiple sclerosis. J AAPOS. 2009;13:13–5.CrossRefPubMedGoogle Scholar
  13. 13.
    Sajjadi M, Sonbolestan SA, Abtahi SM, Abtahi ZS. Transposition surgery for WEBINO. Int Ophthalmol. 2017;37(1):271–4.CrossRefPubMedGoogle Scholar
  14. 14.
    Murthy R, Dawson E, Khan S, Adams GG, Lee J. Botulinum toxin in the management of internuclear ophthalmoplegia. J AAPOS. 2007;11:456–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2018

Authors and Affiliations

  • An-Guor Wang
    • 1
  1. 1.Department of OphthalmologyTaipei Veterans General Hospital, National Yang-Ming University School of Medicine, Yun-San Ophthalmology Education Research FoundationTaipeiTaiwan

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