The three studies above suggested that occlusion and prisms are used mainly to maintain single vision post‐operatively in patients, who had undergone either surgical procedures or botulinum toxin injections.38-40 Prisms may also be considered as a management option of small magnitude deviations, which typically, are not found in patients with WEBINO but may be found in patients with other variants of internuclear ophthalmoplegia. This review will provide current perspectives on the pathogenesis, prognosis and management of WEBINO syndrome. Due to the limited literature published on both surgical intervention and botulinum toxin injection for the management of internuclear ophthalmoplegia, it is difficult to conclude at this time that either option has an advantage over the other. Shakespeare, in using wall-eyed as a term of reproach (as wall-eyed rage, a wall-eyed wretch), alludes probably to the idea of unnatural or distorted vision. Valdeygthr, or vagleygr; fr. It is an eye which is utterly and …

Multiple sclerosis affects up to 400,000 Americans, 23,700 Australians and 2.5 million people worldwide.32, 33 As multiple sclerosis is characterised by episodes of relapsing clinical signs and symptoms, so may the signs and symptoms of any associated internuclear ophthalmoplegia,34 which has been estimated to occur in up to 40 per cent of patients with multiple sclerosis.2 Around 85 per cent of multiple sclerosis cases originate with the relapsing‐remitting form of the disease,32 which is characterised by inflammation, demyelination, axonal transection and remyelination.32 It is generally accepted that demyelinating lesions in the medial longitudinal fasciculus are linked with presence of internuclear ophthalmoplegia.35 As remyelination is part of the relapsing‐remitting form of the disease, an inference may be made that it is possible for any internuclear ophthalmoplegia that may have evolved in association with multiple sclerosis to resolve spontaneously with remyelination.

That same patient also exhibited a medial rectus palsy, which would indicate that the pons lesion may actually have extended into the midbrain as well. WEBINO also impacts the vestibular eye movement pathways via lesions in the medial longitudinal fasciculus. The magnitudes of the exotropia ranged from 25Δ to over 100Δ. Additionally, all patients exhibited improvement in their ability to converge and seven patients regained binocular single vision according to Worth Four Dot testing. We would usually describe a wall-eyed person as having an exotropia.. Before using our website, please read our Privacy Policy. Very few studies have specified the type of exotropia observed in patients with WEBINO. Adams, Leavitt and Holmes38 reviewed the outcomes of three WEBINO patients due to multiple sclerosis, who underwent bilateral resection and recession surgery to correct large angle exotropia and disabling diplopia. The major neurological pathways involved in WEBINO are those underlying horizontal conjugate eye movements and vestibular ocular movements.3 The horizontal conjugate eye movement pathway begins at the level of the pons, where the two abducens nerve nuclei and the paramedian pontine reticular formation (PPRF) reside.4 The paramedian pontine reticular formation receives signals from the superior colliculus and higher cortical centres, such as the frontal eye fields and the occipital and parietal lobes and relays the signal to the ipsilateral abducens nerve nucleus.5 The paramedian pontine reticular formation contains neurons that are responsible for the generation of horizontal saccades, which are one type of horizontal conjugate eye movement.6 The signals generated by the paramedian pontine reticular formation neurons travel to the ipsilateral abducens nerve nucleus and trigger the activation of the abducens nerve nucleus. Five patients suffered internuclear ophthalmoplegia caused by brain haemorrhage and four patients suffered internuclear ophthalmoplegia due to multiple sclerosis. Due to the large magnitude of the exodeviations, every patient underwent either unilateral or bilateral recession‐resection procedures. Adams, Leavitt and Holmes38 also acknowledged the role of prisms in the management of diplopia in WEBINO patients by incorporating a prism for one of the patients to correct a small angle exotropia that recurred after the initial surgery. A lesion from any source that damages the medial longitudinal fasciculus bilaterally can result in WEBINO. It is not difficult to imagine that a lesion along the medial longitudinal fasciculus can cause considerable ocular motility deficits concerning vestibular balance of the two eyes as well as horizontal eye movements.

This unique feature distinguishes them from other organisms... Dinosaurs represented a major turn in the evolutionary development of organisms on Earth. Several theories have been postulated but most have lacked supporting neuroimaging. Archivos de la Sociedad Española de Oftalmología (English Edition). The current literature offers two major management options for diplopia that persists after treatment of any underlying systemic condition, namely, surgery and botulinum toxin injections. In WEBINO, which is a variant of bilateral internuclear ophthalmoplegia, the lesion affects the medial longitudinal fasciculus bilaterally and results in bilateral adduction impairment and nystagmus only in the abducting eye. The results of the surgery demonstrated significant reduction in exodeviations and only one patient remained diplopic. Ushio and colleagues17 quantified and classified the type of exotropia observed in a patient with WEBINO, as an alternating exotropia of large magnitude but this is only one of the few studies where the type of exotropia is explicitly stated. After examining five different studies over the span of 50 years, a discernible pattern seems to exist when comparing the type of internuclear ophthalmoplegia with associated etiologies.20, 24-27 As noted in Tables 2 and 3, ischaemia tends to be more frequently associated with unilateral internuclear ophthalmoplegia, whereas multiple sclerosis is more commonly associated with bilateral internuclear ophthalmoplegia.20, 24-27.

When “looks” can be deceiving - Internuclear ophthalmoplegia after mild traumatic brain injury: Case report and literature review.

His books, video lectures, and training resources can be found at: You have entered an incorrect email address! Having an eye of a very light gray or whitish colour. Chen and Lin15 also evaluated the medial rectus subnucleus hypothesis. The name is based on its structu..

In a different retrospective review of patients with internuclear ophthalmoplegia, Bolaños, Lozano and Cantú31 found only nine out of 24 (38 per cent) patients with ischaemic internuclear ophthalmoplegia demonstrated spontaneous recovery. This term isn’t really used in medicine, but is very descriptive. The content on this website is for information only. WEBINO syndrome (wall-eyed bilateral internuclear ophthalmoplegia) secondary to ischemic stroke, about a case. Typically, management of WEBINO is centred on eliminating diplopia, which is one of the most common complaints reported by patients. They differ from the other vascular plants in producing seeds that germinate into a new.. Mutations can also influence the phenotype of an organism. Use the link below to share a full-text version of this article with your friends and colleagues. The opposite would be cross-eyed ().). The eye with poorer vision can usually be corrected with glasses or contact lenses, or patching therapy.


Seed plants are vascular plants. This suggests that WEBINO may still occur even with an intact oculomotor nerve nucleus.21 In the end, Chen and Lin15 concluded that WEBINO is not necessarily pontine in origin and the responsible lesion extends into the midbrain as well.
Another case report40 of botulinum toxin injection also showed outcomes that were considered suboptimal as most of the patients required maintenance injections or eventually opted for surgery. Multiple Sclerosis Presenting with Bilateral Internuclear Ophthalmoplegia (INO).

Another medical term for it is heterotropia. Caudal paramedian midbrain infarction: a clinical study of imaging, clinical features and stroke mechanisms. It appears that there are actually small subgroups of medial rectus neurons embedded within the medial longitudinal fasciculus.

Smaller lesions may be more likely to resolve spontaneously. Gonyea's pontine hypothesis20 is based on the discovery of concurrent left peripheral facial weakness in a WEBINO patient, as the pons is where the facial nerve nuclei reside and where its tracts leave. You better sign up to Dr. Root's email list to get his latest ocular tips and tricks! Murthy and colleagues39 reviewed 16 patients (13 with bilateral internuclear ophthalmoplegia and three with unilateral internuclear ophthalmoplegia), who underwent botulinum toxin injections in managing non‐resolving diplopia and poor cosmesis. A discussion will follow regarding associated aetiology, as well as current perspectives on the prognosis and management options. Great for ophthalmology, optometry, or medical students who want to learn ocular pathology as quickly as possible. Additional associated neurological symptoms such as oscillopsia and vertigo are sometimes present in more complicated cases of WEBINO, and are more challenging to manage. WEBINO has several characteristic clinical signs, namely, large exotropia in primary gaze, impairment of adduction, dissociated nystagmus in the abducting eye, vertical gaze‐evoked nystagmus and impaired vertical vestibulo‐ocular reflex.1, 3-5, 8, 13, 14 Most of WEBINO's clinical signs can be explained with a general understanding of the major neurological pathways implicated in WEBINO. Although numerous diseases can create lesions within the medial longitudinal fasciculus, the two most commonly associated aetiologies are brainstem infarctions from vascular causes and multiple sclerosis. Each patient received an average of 3.5 injections into one or both lateral recti muscles over the course of the treatment.

Viruses possess both living and non-living characteristics.

wall-eyed But it goes by other popular names too including wandering eyes, …

As the paretic medial rectus receives additional innervation, the corresponding synergist muscle, the contralateral lateral rectus also receives additional innervation. The abducens nerve nucleus then sends an excitatory signal through the medial longitudinal fasciculus (MLF) to the ipsilateral lateral rectus and the contralateral medial rectus subnucleus of the oculomotor nerve, subsequently activating the respective medial rectus.7 Figure 1 illustrates the horizontal conjugate eye movement pathways. © 2001-2020 BiologyOnline.

In terms of other less common causes of internuclear ophthalmoplegia, prognosis is mainly based upon the few case reports that pertain to each specific aetiology. The wall-eyed monocular internuclear ophthalmoplegia (WEMINO) syndrome is a rare pre-nuclear variant of internuclear ophthalmoplegia (INO) with ipsilateral exotropia and associated with an infarct of the paramedian pontine tegmentum, including the medial longitudinal fasciculus (MLF) [7, 8]. The prognosis of internuclear ophthalmoplegia may be inferred from case series that have been conducted throughout the decades. Any information here should not be considered absolutely correct, complete, and up-to-date. A simple way to describe eyes that turn outward. See the note under wall-eye. At this time, the cause of exotropia in WEBINO is still under debate and research. The goals of surgery included one or more of the following: elimination of diplopia, restoration of stereopsis or reduction of abnormal head posture. Number of times cited according to CrossRef: Síndrome de WEBINO (wall-eyed bilateral internuclear ophthalmoplegia) secundario a ictus isquémico, a propósito de un caso. It has been hypothesised that the exotropia associated with WEBINO comes from either a lesion localised to the pontine portion of the brainstem or direct involvement of the oculomotor nerve nucleus in the midbrain.18, 19 For example, Gonyea20 contended that a pontine lesion causes the exotropia seen in patients with WEBINO.


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