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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 34  |  Issue : 1  |  Page : 68-70

Case of multiple sclerosis presenting as unilateral internuclear ophthalmoplegia


Department of Ophthalmology, Goa Medical College, Bambolim, Goa, India

Date of Submission21-Jun-2021
Date of Acceptance07-Jul-2021
Date of Web Publication21-Apr-2022

Correspondence Address:
Dr. Aishwarya M Angadi
2-10-786/16 “Aishwarya Nilaya” Bejai Nodu Lane, Mangalore - 575 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_148_21

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  Abstract 


A 30-year-old female presented with complaints of decreased vision and diplopia since 1 week along with headache and gait disturbances. Examination revealed medial restriction of ocular movements in the right with left abducting nystagmus suggestive of right-sided internuclear ophthalmoplegia and right-sided facial palsy. The patient was admitted under neurology as a suspected case of demyelinating disorder. Magnetic resonance imaging with gadolinium contrast revealed features suggestive of probably multiple sclerosis (MS). The patient was given 5 days of high-dose intravenous steroids following which the patient showed improvement and was discharged on multivitamins. Subsequent follow-up showed significant improvement in symptoms, visual acuity, and ocular movements. Hereby presenting a rare case of MS presenting as unilateral internuclear ophthalmoplegia.

Keywords: Internuclear ophthalmoplegia, magnetic resonance imaging, multiple sclerosis, neuro-ophthalmology


How to cite this article:
Angadi AM. Case of multiple sclerosis presenting as unilateral internuclear ophthalmoplegia. Kerala J Ophthalmol 2022;34:68-70

How to cite this URL:
Angadi AM. Case of multiple sclerosis presenting as unilateral internuclear ophthalmoplegia. Kerala J Ophthalmol [serial online] 2022 [cited 2022 Aug 15];34:68-70. Available from: http://www.kjophthal.com/text.asp?2022/34/1/68/343671




  Introduction Top


Multiple sclerosis (MS) is an immune-mediated inflammatory disease that attacks and destroys the myelinated axons in the central nervous system.[1],[2] MS is more common in females than males between the age of 20 and 40 years.[3] The cause of MS is unknown. MS results in various ophthalmic findings of which, commonly presenting symptoms include optic neuritis (seen in 20% cases as primary presentation), internuclear ophthalmoplegia (bilateral > unilateral), and nystagmus. Unusual presentations include visual field loss, gaze palsies, and isolated ocular motor palsies.[4] Internuclear ophthalmoplegia is characterized by a deficit in ipsilateral adduction with contralateral abducting nystagmus which mainly occurs due to lesion in the medial longitudinal fasciculus.[5],[6] Causes of internuclear ophthalmoplegia are MS, brain infarction, head trauma, infection, hydrocephalus, brainstem tumors, and lupus erythematosus.[7] There can be varied presentations in MS as it can affect any white matter tract of the central nervous system and also no single test can diagnose MS, hence diagnosis is based on both clinical examination and laboratory evaluation. We hereby report a case of MS presenting as unilateral internuclear ophthalmoplegia.


  Case Report Top


A healthy 30-year-old female presented to our outpatient department with a history of blurring of vision and diplopia of 1 week duration, which aggravated on left-sided gaze. She had a headache which was generalized throbbing type along with gait disturbances and also on and off tingling and numbness of the upper and lower extremities. The patient was not a known case of any systemic illness. There was no history of ocular trauma, head injury, or chronic drug intake prior to the episode. There was no significant past history or family history. On examination, visual acuity was 20/50 OU which did not improve with pinhole. Pupils were 3 mm reacting to both direct and consensual light reflex. Ocular movements were restricted medially in the right eye with horizontal nystagmus on abduction of the left eye suggestive of right internuclear ophthalmoplegia [Figure 1]. Rest of the anterior segment of both eyes by slit-lamp examination, including intraocular pressure was within normal limits. Color vision, dilated fundoscopy, and visual field testing by Humphreys field analyzer were within normal limits in both eyes. Neurological examination revealed right facial weakness, gait ataxia with brisk deep tendon reflexes. As a demyelinating disease was suspected, magnetic resonance imaging (MRI) was done and showed multiple lesions along with the subcortical and periventricular white matter in bilateral fronto-temporo-parieto-occipital region, bilateral centrum semiovale, perpendicular to callososeptal interface, the brainstem and cerebellum showing varying degrees and patterns of enhancement all these features suggestive of demyelinating disorder, likely MS [Figure 2]. The patient's Vitamin D level was below normal. Lumbar puncture was done and oligoclonal bands and raised chloride level was detected in cerebrospinal fluid. The patient was also positive for antineutrophil cytoplasmic antibody in the serum. Rest of the routine blood investigations were within normal limits. The patient received 5 days of high-dose injectable steroids, after clearance from physician, and showed symptomatic improvement within a week. Following which she was shifted to oral steroids according to body weight and was discharged on multivitamin and calcium supplements. Follow-up examination of the patient after 6 weeks showed improvement in terms of vision and ocular movements and did not have symptoms of diplopia.
Figure 1: Picture showing ocular movements in all 9 gazes, suggestive of right-sided internuclear ophthalmoplegia

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Figure 2: T2-weighted magnetic resonance imaging showing white matter hyperintensity and also hyperintensity in the pericallosal region suggestive of Dawson finger

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  Discussion Top


The most common presentation of MS is optic neuritis, internuclear ophthalmoplegia. Unilateral internuclear ophthalmoplegia is much less common presenting feature when compared to bilateral in a case of MS. The primary symptom of internuclear ophthalmoplegia is diplopia on lateral gaze because of paresis of the adducting eye and is a strong evidence of MS; however systemic lupus erythematosus and small basilar artery strokes may also cause it. The cause of internuclear ophthalmoplegia is commonly MS in young adults especially when the syndrome is bilateral. But ours is a rare case of MS presenting as unilateral internuclear ophthalmoplegia. The patient on investigating had the presence of oligoclonal band in the cerebrospinal fluid analysis had low levels of vitamin D and also MRI lesions suggestive of MS. Combining both examination and investigations she was diagnosed as a case of MS.


  Conclusion Top


MS should be a differential diagnosis in young patients presenting with visual loss, ocular movement disorders, gaze palsies (unilateral/bilateral). It is difficult to come to a diagnosis of MS as there is no single diagnostic test but it is a combination of clinical and laboratory evaluation.

Acknowledgment

We would like to express our sincere gratitude to Dr. Aparna G. Naik (Lecturer, Department of Ophthalmology, Goa Medical College) for her invaluable guidance and encouragement in the successful completion of this case report.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Multiple Sclerosis: Practice Essentials, Background, Pathophysiology. Available from: https://emedicine.medscape.com/article/1146199-overview. [Last accessed on 2021 Jun 18].  Back to cited text no. 1
    
2.
Diagnosis and Treatment of Multiple Sclerosis | The BMJ. Available from: https://www.bmj.com/content/332/7540/525.short. [Last accessed on 2021 Jun 18].  Back to cited text no. 2
    
3.
Harbo HF, Gold R, Tintoré M. Sex and gender issues in multiple sclerosis. Ther Adv Neurol Disord 2013;6:237-48.  Back to cited text no. 3
    
4.
Chen L, Gordon LK. Ocular manifestations of multiple sclerosis. Curr Opin Ophthalmol 2005;16:315-20.  Back to cited text no. 4
    
5.
Internuclear Ophthalmoplegia-EyeWiki. Available from: https://eyewiki.aao.org/Internuclear_Ophthalmoplegia. [Last accessed on 2021 Jun 18].  Back to cited text no. 5
    
6.
Sharma R, Saxena R, Bhatia R, Menon V. Multiple Sclerosis – An Ophthalmologist's perspective.DJO 2013;23:251-256. Available from: https://www.djo.org.in/articles/23/4/multiple-sclerosis-an-ophthalmologists-perspective.html. [Last accessed on 2021 Dec 15].  Back to cited text no. 6
    
7.
Obuchowska I, Mariak Z. Internuclear ophthalmoplegia – Causes, symptoms and management. Klin Oczna 2009;111:165-7.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
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