Morgan Howells-Resendez, MD
Resident Physician
East Carolina University Health Medical Center
Greenville, North Carolina, United States
Robert T. Lombard, MD
Assistant Clinical Professor
ECU Health Medical Center
Greenville, North Carolina, United States
Wall-eyed bilateral internuclear ophthalmoplegia (WEBINO), is a rare neuro-ophthalmological phenomenon with features of exotropia of both eyes, bilateral internuclear ophthalmoplegia as well as abducting nystagmus in both eyes.
Case Description:
33 year-old female with history of thrombotic thrombocytopenic purpura and prior right frontal infarct was brought into the hospital after being found unresponsive at home. Preceding this admission, patient had been consuming a diet limited to only Gatorade and hard candies. Work-up overall concerning for Wernicke encephalopathy in the setting of severe malnutrition. Exam on admission demonstrated walled eyes with bilateral INO. MRI brain noted flair signal abnormalities around the dorsum of the pons, periventricular matter of third ventricle and acqueductal gray matter, and bilateral medial thalamus, supportive of Wernicke encephalopathy diagnosis. Patient admitted to inpatient rehabilitation where she continued to receive thiamine for Wernicke encephalopathy as well as visual retraining with occupational therapy. During admission, patient’s diplopia and WEBINO began to resolve. Repeat MRI brain four weeks after event showed near complete resolution of changes that were seen on previous imaging. At outpatient follow-up, patient’s visual deficits had resolved.
Discussions:
WEBINO is caused by damage to medial longitudinal fasciculi bilaterally in the brainstem, most commonly due to midbrain infarction in elderly patient as well as demyelinating disease in younger patients. Damage to the MLF causes a primary position exotropia (Wall-eyed), and lesion in the ascending tracks from the vestibular nuclei leads to vertical gaze-evoked nystagmus on superior gaze. WEBINO has rarely been associated with severe nutritional deficiencies.
Conclusions:
While most commonly associated with demyelinating diseases or midbrain infarctions, it is important to consider Wernicke encephalopathy and to obtain a thorough nutritional history in encephalopathic patients with WEBINO on physical exam.
