WALL-EYED BILATERAL INTERNUCLEAR OPHTHALMOPLEGIA
(WEBINO SYNDROME) AND MYELOPATHY IN
PYODERMA GANGRENOSUM
MARCO AURÉLIO LANA * — PAULO ROBERTO R. MOREIRA ** LEONARDO B. NEVES ***
S U M M A R Y — A 3 5 - y e a r - o l d f e m a l e w i t h p y o d e r m a g a n g r e n o s u m d e v e l o p e d p a r a p a r e s i s w i t h a s e n s o r y l e v e l a t L 1 . T h r e e m o n t h s l a t e r s h e c o m p l a i n e d o f d i p l o p i a a n d w a s f o u n d t o h a v e b i l a t e r a l i n t e r n u c l e a r o p h t h a l m o p l e g i a w i t h e x o t r o p i a a n d n o o c u l a r c o n v e r g e n c e . T h e t e r m W e b i n o s y n d r o m e h a s b e e n c o i n e d t o d e s i g n t h i s s e t o f n e u r o - o p t h a l m o l o g i c f i n d i n g s . A l t h o u g h i t w a s i n i t i a l l y a t t r i b u t e d t o l e s i o n s a f f e c t i n g t h e m e d i a l l o n g i t u d i n a l f a s c i c u l u s a n d t h e m e d i a l r e c t u s s u b n u c l e i o f t h e o c u l o m o t o r c o m p l e x i n t h e m i d b r a i n t h e e x a c t l o c a t i o n o f t h e l e s i o n i s s t i l l d i s p u t e d . I n t h e p r e s e n t c a s e b o t h m y e l o p a t h y a n d W e b i n o s y n d r o m e w e r e p r o b a b l y d u e t o v a s c u l a r o c c l u s i v e d i s e a s e r e s u l t i n g f r o m c e n t r a l n e r v o u s s y s t e m v a s c u l i t i s o c c u r r i n g i n c o n c o m i t a n c e t o p y o d e r m a g a n g r e n o s u m .
O f t a l m o p l e g i a i n t e r n u c l e a r b i l a t e r a l e e x o t r o p i a ( s í n d r o m e d e W e b i n o ) e m i e l o p a t i a n o p y o d e r -m a g a n g r e n o s u -m .
R E S U M O — O t e r m o W e b i n o é f o r m a d o p e l a s i n i c i a i s d o s c o m p o n e n t e s d a s í n d r o m e ( w a l l -e y -e d b i l a t -e r a l i n t -e r n u c l -e a r o p h t h a l m o p l -e g i a ) , h a v -e n d o t a m b é m p -e r d a d a c o n v -e r g ê n c i a o c u l a r . R e l a t a m o s o c a s o d e u m a p a c i e n t e d e 3 5 a n o s d e i d a d e , c o m p i o d e r m a g a n g r e n o s u m , q u e d e s e n v o l v e u s u b i t a m e n t e m i e l o p a t i a c o m n í v e l s e n s i t i v o e m L1 e , t r ê s m e s e s d e p o i s , q u a d r o s ú b i t o d e o f t a l m o p l e g i a i n t e r n u c l e a r b i l a t e r a l , e x o t r o p i a e p e r d a d e c o n v e r g ê n c i a . H á p o u c o s c a s o s d e s í n d r o m e d e W e b i n o r e l a t a d o s n a l i t e r a t u r a , a m a i o r i a d e l e s s e c u n d á r i a a e s c l e r o s e m ú l t i p l a e a d o e n ç a v a s c u l a r c e r e b r a l . A l o c a l i z a ç ã o d a l e s ã o r e s p o n s á v e l p e l a s í n d r o m e a i n d a n ã o e s t á b e m e s t a b e l e c i d a m a s , a c r e d i t a - s e q u e o s f a s c í c u l o s l o n g i t u d i n a i s m e d i a i s e o s s u b n ú c l e o s d o s r e t o s m e d i a i s d o c o m p l e x o o c u l o m o t o r n o m e s e n c é f a l o s e j a m a f e t a d o s , e m b o r a n ã o h a j a a i n d a c o n f i r m a ç ã o a n á t o m o p a t o l ó g i c a . O p i o d e r m a g a n g r e n o s u m é c o n d i ç ã o c a r a c t e r i z a d a p o r ú l c e r a s d e c r e s c i m e n t o r á p i d o e d e b o r d a s e l e v a d a s c o m h a l o e r i t e m a t o s o l o c a l i z a -d a s p r e f e r e n c i a l m e n t e n a c a b e ç a , t r o n c o e m e m b r o s i n f e r i o r e s . E m b o r a s u a n a t u r e z a a i n -d a s e j a d e s c o n h e c i d a , p a r e c e s e r s e c u n d á r i o a v a s c u l i t e s u b j a c e n t e , e s t a n d o a s s o c i a d o a g r a n d e v a r i e d a d e d e d o e n ç a s s i s t ê m i c a s . N o c a s o p r e s e n t e , a o c o r r ê n c i a d a s í n d r o m e d e W e b i n o e d e m i e l o p a t i a s u g e r e a u e a s l e s õ e s n o s i s t e m a n e r v o s o s e j a m d e n a t u r e z a v a s c u l a r , p r o v a -v e l m e n t e s e c u n d á r i a s a -v a s c u l i t e . E s t e é o p r i m e i r o r e l a t o da l i t e r a t u r a d e c o m p l i c a ç õ e s n e u r o l ó g i c a s d o p i o d e r m a g a n g r e n o s u m e d a a s s o c i a ç ã o d e m i e l o p a t i a à s í n d r o m e . d e W e b i n o .
Wall-eyed bilateral internuclear ophthalmoplegia (Webino syndrome) is a variant
of Cogan's anterior internuclear ophthalmoplegia with exotropia in primary position.
It has been attributed to lesions affecting the medial longitudinal fasciculus and the
medial rectus subnuclei of the oculomotor complex. Only a few cases of Webino
syndrome have been reported in the literature. W e describe a patient with pyoderma
gangrenosum who developed bilateral internuclear ophthalmoplegia with exotropia, loss
of convergence and myelopathy in the course of the disease. T o our knowledge neither
neurological complications of pyoderma gangrenosum nor association of Webino
syn-drome to myelopathy have been described previously.
F e d e r a l U n i v e r s i t y o f M i n a s G e r a i s M e d i c a l S c h o o l ( U F M G ) : * A s s o c i a t e d P r o f e s s o r o f
N e u r o l o g y ; * * N e u r o l o g i s t ; * * * D e r m a t o l o g i s t .
C A S E R E P O R T
M S L . , a 3 5 - y e a r - o l d f e m a l e w>as a d m i t t e d t o t h e h o s p i t a l w i t h h i s t o r y o f r e c u r r e n t u l c e r s i n l e f t a r m a n d t h i g h s i n c e t h e a g e o f I S y e a r s . I n t h e l a s t t w o y e a r s s h e d e v e l o p e d c h r o n i c u r i n a r y i n f e c t i o n a n d h a d b e e n t r e a t e d w i t h a n t i b i o t i c s . S h e h a d a l s o b e e n g i v e n t a l i d o m i d e , c h l o r p h a z i m i n e a n d D D S a s t r e a t m e n t f o r p y o d e r m a g a n g r e n o s u m i n a n o t h e r h o s p i t a l , w h e r e t h e d i a g n o s i s w a s m a d e t h r o u g h a s k i n b i o p s y . O n a d m i s s i o n t h e p a t i e n t p r e s e n t e d a l a r g e p a i n f u l n e c r o t i c u l c e r s u r r o u n d e d b y a n e r y t h e m a t o u s h a l o i n t h e l e f t t h i g h ( F i g . 1 ) a n d s i g n s o f o l d i n a t i v e d e r m a t o l o g i o a l l e s i o n s o n t h e l e f t a r m . T h e r e w a s n o n e u r o l o g i c a l o r o p h t h a l m o l o g i c a l c o m p l a i n t . P h y s i c a l e x a m i n a t i o n w a s u n r e v e a l i n g e x c e p t f o r t h e s k i n l e s i o n s . A d m i s s i o n l a b o r a t o r y w o r k - u p w a s a s f o l l o w s : r e d b l o o d c e l l c o u n t 3 , 5 0 0 , 0 0 0 p e r c u b i c m i l l i m e t e r , h e m o g l o b i n 1 0 , 5 g / d L , h e m a t o c r i t 3 5 % , a n d w h i t e b l o o d c e l l c o u n t 5 , 3 0 0 p e r c u b i c m i l l i m e t e r . S e r u m g l u c o s e , c r e a t i n i n e , B U N , t h y r o i d a n d l i v e r f u n c t i o n s t u d i e s a n d p r o t e i n e l e c t r o p h o r e s i s s h o w e d n o r m a l v a l u e s . S e r u m V D R L , F T A A B S , a n t i -n u c l e a r a -n t i b o d y t i t e r s L E c e l l p r e p a r a t i o -n w e r e a l s o -n e g a t i v e a s w e r e r o e -n t g e -n o g r a m s o f t h e c h e s t a n d g a s t r o i n t e s t i n a l s e r i e s . B i o p s y s p e c i m e n s t a k e n f r o m t h e e r y t h e m a t o u s a r e a a t t h e b o r d e r o f t h e l e s i o n o n p a t i e n t ' s l e f t t h i g h d i s c l o s e d l y m p h o c y t i c v a s c u l i t i s w i t h e n d o t h e l i a l s w e l l i n g , f i b r o n o i d n e c r o s i s a n d e x t r a v a s a t i o n o f e r y t h r o c y t e s a n d l y m p h o c y t e s ( F i g . 1 ) . A s t h e p a t i e n t w a s b e i n g t r e a t e d w i t h a z a t h i o p r i n e a n d s t e r o i d s s h e s u d d e n l y d e v e l o p e d p a r a p a r e s i s a n d u r i n a r y r e t e n t i o n . N e u r o l o g i c a l c o n s u l t a t i o n a t t h i s t i m e d i s c l o s e d p a r a p a r e s i s w i t h a s e n s o r y l e v e l a t L i . T h e d e e p t e n d o n r e f l e x e s w e r e h y p o a c t i v e a n d B a b i n s k i s i g n c o u l d n o t b e e l i c i t e d . L u m b a r p u n c t u r e s h o w e d a n o p e n i n g p r e s s u r e o f 1 2 0 m m H20 , c l e a r c e r e b r o s p i n a l f l u i d w i t h 3 l y m p h o c y t e s p e r c u b i c m i l l i m e t e r , g l u c o s e c o n t e n t
m o n t h s l a t e r w h i l e o i l p h y s i c a l t h e r a p y s h e s u d d e n l y e x p e r i e n c e d l e f t h e m i p a r e s i s a n d d i p l o p i a . N e u r o l o g i c a l r e - e v a l u a t i o n s h o w e d e x o t r o p i a i n p r i m a r y p o s i t i o n , b i l a t e r a l m e d i a l r e c t u s p a l s y o n a t t e m p t e d h o r i z o n t a l g a z e o n e i t h e r d i r e c t i o n w i t h n y s t a g m u s o f t h e a b d u c t i n g e y e ( F i g . 2 ) . V e r t i c a l g a z e w a s n o r m a l a n d t h e r e w a s a l o s s o f o c u l a r c o n v e r g e n c e . T h e p u p i l s w e r e 3 m m i n s i z e , r o u n d a n d f u l l y r e a c t i v e t o l i g h t . F u n d o s c o p i c e x a m i n a t i o n a n d v i s u a l f i e l d s w e r e n o r m a l . T h e r e w e r e a l e f t c e n t r a l f a c i a l w e a k n e s s , m o d e r a t e l e f t h e m i p a r e s i s a n d a r e s i d u a l w e a k n e s s o n t h e r i g h t l o w e r l i m b . M u s c l e s t r e t c h r e f l e x e s w e r e d e c r e a s e d o n t h e l e f t u p p e r l i m b b u t b r i s k o n b o t h l o w e r e x t r e m i t i e s . B i l a t e r a l B a b i n s k i s i g n w a s p r e s e n t a n d s e n s o r y l e v e l a t L , l p e r s i s t e d u n c h a n g e d . H i g h q u a l i t y c o m p u t e d t o m o g r a p h i c s c a n o f t h e h e a d e x h i b i t e d n o a b n o r m a l i t i e s .
C O M M E N T S
Internuclear ophthalmoplegia is a well-characterized clinical syndrome manifested
by paresis of adduction on attempted horizontal gaze associated with jerk nystagmus
of the abducting eye. Vertical nystagmus with attempted upward gaze and loss of
convergence may be concomitant features- Although the clinical description of the
syndrome is attributed to Wilson se j
n1906, some authors 1 3 date back its recognition
to about 1864. The role of the medial longitudinal fasciculus ( M L F ) in mediation of
conjugate eye movements was first suspected by M u s k e n s
2 2as early as 1914. This
suspection was confirmed ten years later through the first pathological study of a
case of internuclear ophthalmoplegia 3 1 . Since then it has been well demonstrated that
lesions involving the MLF connecting the pontine paramedian reticular formation
( P P R F ) and the ipsilateral abducens nucleus with the contralateral medial rectus
subnucleus in the midbrain produce failure of the medial rectus on the side of the
lesion to act in horizontal gaze and nystagmus of the abducting eye. Weakness of
adduction may range from complete inability to adduct the eye beyond midline to only
a mild decrease in velocity of adducting saccades without any limitation of adduction.
The origin of the contralateral abducting nystagmus is still a matter of controversy,
borne authors believe that it may reflect the effects of convergence 3 3 , impaired
inhibi-tion of the contralateral medial rectus 2 4 interrupinhibi-tion of descending internuclear fibers
projecting to the abducens nucleus 1 4 , a gaze-evoked n y s t a g m u s
3, or even adaption
to the contralateral medial adduction w e a k n e s s
2.
and infections are less frequent causes. On the other hand the most common cause
of bilateral internuclear ophthalmoplegia is multiple sclerosis 5 although posterior fossa
tumors6, brainstem infection^, Arnold-Chiari malformations with hydrocephalus6,
head trauma 1 . 2 5 , basilar artery disease 8 , carcinomatous meningitis 9 , tuberculous
meningitis 1 6 , cryptococcal meningitis n , systemic lupus erythematosus 7 , intrathecal
chemotherapy and cranial irradiation 1 8 , syphilis 2 9 , periarteritis n o d o s a
4,
spinocere-bellar degenerations 3 5 and branched-chain ketoaminociduria 1 9 . Myasthenia gravis 5 ,
abetalipoproteinemia 3 7 and coma caused by overdose of phenytoin 3 0 , n a r c o t i c s
2 6or
barbiturates
2 3 , 2 7may produce ocular findings similar to bilateral internuclear
opthal-moplegia.
The term Webino syndrome (wall-eyed bilateral internuclear ophthamoplegia)
was coined by L u b o w
36 to describe patients with bilateral adduction paresis, absence
of ocular convergence and exotropia. Lubow believed that the syndrome was caused
by lesions involving the medial longitudinal fasciculus bilaterally in the midbrain
together with the medial rectus subnuclei of the oculomotor complex. There have
been only a few cases of Webino syndrome reported in the literature, most of them
caused by occlusive vascular or demyelinating diseases
1 0 . 2 0 , 3 2 .An additional case
was due to a tuberculous granuloma in the midbrain that presumably affected the
MLF and the medial rectus subnuclei of the oculomotor complex by mass e f f e c t
1 6.
In a recent reported case of Webino syndrome caused by multiple sclerosis autopsy
did not reveal any lesion in the medial rectus subnuclei of the oculomotor complex
leading their authors 3 2 to suppose that lesions in more than one locus may be
respon-sible for eliciting the syndrome. Others have attributed the syndrome to lesions
affecting the PPRF and the M L F but this hypothesis has not been confirmed by
pathological studies. A s loss of convergence is concerned a supplemental anatomic
explanation may not be necessary as it commonly occurs in long-standing disruptions
of ocular fusion 1 0 . it has been proposed however that interruption of corticofugal
fibers from frontal, parietal or occipital eye fields may play a role in the convergence
dysfunction 3 2 .
Pyoderma gangrenosum is an uncommom ulcerative skin condition with
dis-tinctive clinical appearance comprising a destructive burrowing ulcer with an irregular
margin and a ragged purple-red overhanging edge 1 5 . it typically starts as an isolated
sterile pustule or nodule, often on one of the lower extremities but rapidly breaks
down and evolves into an ulcer that is painful, enlarging and necrotic. It has been
reported in association with a wide variety of systemic diseases including ulcerative
colitis, Crohn's disease, rheumatoid arthritis, chronic myeloid leukemia,
agammaglo-bulinemia, respiratory infections and post-surgical interventions 1 2 . Histopathologic
and immunopathologic study 3 4 of pyoderma gangrenosum has shown the most
charac-teristic changes are those of lymphocytic vasculitis, mild fibrinoid necrosis of the
blood vessel walls, disruption of the blood vessel structure and thromboses of the
lumen of the vessels.
It seems reasonable to assume therefore that the lesions involving brainstem
structures causing Webino syndrome and that causing myelopathy in the present case
probably resulted from vasculitis and occlusive vascular disease.
R E F E R E N C E S
1. B a k e r R S — I n t e r n u c l e a r o p h t h a l m o p l e g i a f o l l o w i n g h e a d i n j u r y . J N e u r o s u r g 5 1 : 5 5 2 , 1 9 7 9 .
2 . B a l o h R W , Y e e R D , H o n r u b i a B — I n t e r n u c l e a r o p h t h a l m o p l e g i a : 1. S a c c a d e s a n d d i s s o c i a t e d n y s t a g m u s . A r c h N e u r o l 3 5 : 4 8 4 , 1 9 7 8 .
3. B e n d e r M B , W e i n s t e i n E A — D i s s o c i a t e d m o n o c u l a r n y s t a g m u s w i t h p a r e s i s o f h o r i z o n t a l o c u l a r m o v e m e n t s . A r c h O p h t h a l m o l 2 1 : 2 2 8 , 1 9 3 9 .
4 . C h r i s t o f f N , A n d e r s o n P J , N a t h a n s o n M — P r o b l e m s i n a n a t o m i c a n a l y s i s o f l e s i o n s o f t h e m e d i a l l o n g i t u d i n a l f a s c i c u l u s . A r c h N e u r o l 2 : 2 9 3 , 1 9 6 0 .
5 . C o g a n D G — I n t e r n u c l e a r o p h t h a l m o p l e g i a , t y p i c a l a n d a t y p i c a l . A r c h O p h t h a l m o l 8 4 : 5 8 3 , 1 9 7 0 .
6. C o g a n D G , W r a y S — I n t e r n u c l e a r o p h t h a l m o p l e g i a a s a n e a r l y s i g n o f b r a i n s t e m t u m o r s . N e u r o l o g y 2 0 : 6 2 9 , 1 9 7 0 .
7 . C o g a n M , K l i n n e L B , D u v a l l E R — B i l a t e r a l i n t e r n u c l e a r o p h t h a l m o p l e g i a i n s y s t e m i c l u p u s e r y t h e m a t o s u s . J C l i n N e u r o - O p h t h a l m o l 7 : 6 9 , 1 9 8 7 .
8. D e v e r a u x M W , B r u s t J C M , K e a n e J R — I n t e r n u c l e a r o p h t h a l m o p l e g i a c a u s e d b y s u b d u r a l h e m a t o m a . N e u r o l o g y 2 7 : 2 5 1 , 1 9 7 9 .
R E F E R E N C E S
1. B a k e r R S — I n t e r n u c l e a r o p h t h a l m o p l e g i a f o l l o w i n g h e a d i n j u r y . J N e u r o s u r g 5 1 : 5 5 2 , 1 9 7 9 .
2 . B a l o h R W , Y e e R D , H o n r u b i a B — I n t e r n u c l e a r o p h t h a l m o p l e g i a : 1. S a c c a d e s a n d d i s s o c i a t e d n y s t a g m u s . A r c h N e u r o l 3 5 : 4 8 4 , 1 9 7 8 .
3. B e n d e r M B , W e i n s t e i n E A — D i s s o c i a t e d m o n o c u l a r n y s t a g m u s w i t h p a r e s i s o f h o r i z o n t a l o c u l a r m o v e m e n t s . A r c h O p h t h a l m o l 2 1 : 2 2 8 , 1 9 3 9 .
4 . C h r i s t o f f N , A n d e r s o n P J , N a t h a n s o n M — P r o b l e m s i n a n a t o m i c a n a l y s i s o f l e s i o n s o f t h e m e d i a l l o n g i t u d i n a l f a s c i c u l u s . A r c h N e u r o l 2 : 2 9 3 , 1 9 6 0 .
5 . C o g a n D G — I n t e r n u c l e a r o p h t h a l m o p l e g i a , t y p i c a l a n d a t y p i c a l . A r c h O p h t h a l m o l 8 4 : 5 8 3 , 1 9 7 0 .
6. C o g a n D G , W r a y S — I n t e r n u c l e a r o p h t h a l m o p l e g i a a s a n e a r l y s i g n o f b r a i n s t e m t u m o r s . N e u r o l o g y 2 0 : 6 2 9 , 1 9 7 0 .
7 . C o g a n M , K l i n n e L B , D u v a l l E R — B i l a t e r a l i n t e r n u c l e a r o p h t h a l m o p l e g i a i n s y s t e m i c l u p u s e r y t h e m a t o s u s . J C l i n N e u r o - O p h t h a l m o l 7 : 6 9 , 1 9 8 7 .
9 . F o r d S C . C r u z J , B i l l e r J , W a y m e L , W h i t e D R — B i l a t e r a l i n t e r n u c l e a r o p h t h a l m o p l e g i a i n c a r c i n o m a t o u s m e n i n g i t i s . J C l i n N e u r o - O p h t h a l m o l 3 : 1 2 7 , 1 9 8 3 .
1 0 . G o n y e a E F — B i l a t e r a l i n t e r n u c l e a r o p h t h a l m o p l e g i a : a s s o c i a t i o n w i t h o c c l u s i v e c e r e b r o -v a s c u l a r d i s e a s e . A r c h N e u r o l 3 1 : 1 6 8 , 1 9 7 4 .
1 1 . G o n y e a E F , H e l m a n K M — N e u r o o p h t h a l m i c a s p e c t s o f c e n t r a l n e r v o u s s y s t e m c r y p t o -c o -c -c o s i s . A r -c h O p h t h a l m o l 8 7 : 1 6 4 . 1 9 7 2 .
1 2 . G u i l h o u J J , G u i l l o t B , M e y n a d i e r J — P y o d e r m a g a n g r e n o s u m : 1 4 o b s e r v a t i o n s p e r ¬ s o n n e l l e s e t r e v u e d e l a l i t e r a t u r e . J M a l a d i e s V a s e 1 2 : 2 0 2 , 1 9 8 7 .
1 3 . H a r r i n g t o n R B , H o l l e n h o r s t R W , S a y r e G P — U n i l a t e r a l i n t e r n u c l e a r o p h t h a l m o p l e g i a . A r c h N e u r o l 1 5 : 2 9 , 1 9 6 6 .
1 4 . H e n n V , B u t t n e r - E n n e v e r J A , K e p p K — T h e p r i m a t e o c u l o m o t o r s y s t e m : I . M o t o n e u r o n s : a s y n t h e s i s o f a n a t o m i c a l , p h y s i o l o g i c a l a n d c l i n i c a l d a t a . H u m N e u r o b i o l 1 : 7 7 , 1 9 8 2 . 1 5 . H o l t P J A , D a v i e s M G , S a u n d e r s K C , N u k i G — P y o d e r m a g a n g r e n o s u m : c l i n i c a l a n d
l a b o r a t o r y f i n d i n g s i n 1 5 p a t i e n t s w i t h s p e c i a l r e f e r e n c e t o p o l y a r t h r i t i s . M e d i c i n e 5 9 : 1 1 4 , 1 9 8 0 .
1 6 . I n o c e n c i o F P , B a c e l l e r R — T u b e r c u l o s i s g r a n u l o m a i n t h e m i d b r a i n c a u s i n g w a l l - e y e d b i l a t e r a l i n t e r n u c l e a r o p h t h a l m o p l e g i a ( W e b i n o ) . J C l i n N e u r o - O p h t h a l m o l 5 : 3 1 , 1 9 8 5 . 1 7 . K u p f e r C , C o g a n D G — U n i l a t e r a l i n t e r n u c l e a r o p h t h a l m o p l e g i a : a c l i n i c o p a t h o l o g i c a l
c a s e r e p o r t . A r c h O p h t h a l m o l 7 5 : 4 8 4 , 1 9 6 6 .
1 8 . L e p o r e F E , N i s s e n b l a t t M J — B i l a t e r a l i n t e r n u c l e a r o p h t h a l m o p l e g i a a f t e r i n t r a t e c a l c h e m o t h e r a p y a n d c r a n i a l i r r a d i a t i o n . A m J O p h t h a l m o l 9 2 : 8 5 1 , 1 9 8 1 .
1 9 . M a c D o n a l d J J , S h e r P K — O p h t h a l m o p l e g i a a s a s i g n o f m e t a b o l i c d i s e a s e i n t h e n e w b o r n . N e u r o l o g y 2 7 : 9 7 1 , 1 9 7 7 .
2 0 . M c G e t t r i c k P , E u s t a c e P — T h e w e b i n o s y n d r o m e . N e u r o - O p h t h a l m o l 5 : 1 0 9 , 1 9 8 5 . 2 1 . M i l l e r N R — W a l s h a n d H o y t ' s C l i n i c a l N e u r o - O p h t h a l m o l o g y . E d 4 . W i l l i a m s a n d
W i l k i n s , B a l t i m o r e , 1 9 8 5 .
2 2 . M u s k e n s L J J — A n a n a t o m i c o - p h y s i o l o g i c a l s t u d y o f t h e p o s t e r i o r l o n g i t u d i n a l b u n d l e i n i t s r e l a t i o n t o f o r c e d m o v e m e n t s . B r a i n 3 6 : 3 6 2 , 1 9 1 4 .
2 3 . P l u m F , P o s n e r J B — D i a g n o s i s o f S t u p o r a n d C o m a . E d 3 . F . A . D a v i s , P h i l a d e l p h i a , 1 9 8 0 .
2 4 . P o l a J , R o b i n s o n D A — A n e x p l a n a t i o n o f e y e m o v e m e n t s s e e n i n i n t e r n u c l e a r o p h t h a l -m o p l e g i a . A r c h N e u r o l 3 3 : 4 4 7 , 1 9 7 6 .
2 5 . R i c h J R , G r e g o r i u s F K , H e p l e r R S — B i l a t e r a l i n t e r n u c l e a r o p h t h a l m o p l e g i a a f t e r t r a u m a . A r c h O p h t h a l m o l 9 2 : 6 6 , 1 9 7 4 .
2 6 . R i z z o M , C o r b e t t J — B i l a t e r a l i n t e r n u c l e a r o p h t h a l m o p l e g i a r e v e r s e d b y n a l o x o n e . A r c h N e u r o l 4 0 : 2 4 2 , 1 9 8 3 .
2 7 . S i m o n R P — F o r c e d d o w n w a r d o c u l a r d e v i a t i o n o c c u r r e n c e d u r i n g o c u l o - v e s t i b u l a r t e s t i n g i n s e d a t i v e d r u g - i n d u c e d c o m a . A r c h N e u r o l 3 5 : 4 5 6 , 1 9 7 8 .
2 8 . S m i t h J L — I n t e r n u c l e a r o p h t h a l m o p l e g i a . J C l i n N e u r o - O p h t h h a l m o l 6 : 6 6 , 1 9 8 6 . 2 9 . S m i t h J L , C o g a n D G — I n t e r n u c l e a r o p h t h a l m o p l e g i a : a r e v i e w o f 5 8 c a s e s . A r c h
O p h t h a l m o l 6 1 : 6 8 7 , 1 9 5 9 .
3 0 . S p e c t o r R H , D a v i d o f f R A , S c h w a r t z m a n R J — P h e n y t o i n - i n d u c e d o p h t h a l m o p l e g i a . N e u r o l o g y 2 6 : 1 0 3 1 , 1 9 7 6 .
3 1 . S p i l l e r W G — O p h t h a l m o p l e g i a i n t e r n u c l e a r i s a n t e r i o r : a c a s e w i t h n e c r o p s y . B r a i n 4 7 : 3 4 5 , 1 9 2 4 .
3 2 . S t r o m i n g e r M B , M i n e y E J , S t r o m i n g e r A I , S t r o m i n g e r N D — B i l a t e r a l i n t e r n u c l e a r o p h t h a l m o p l e g i a w i t h a b s e n c e o f c o n v e r g e n t e y e m o v e m e n t s : c l i n i c o p a t h o l o g i c c o r r e l a t i o n . J C l i n N e u r o - O p h t h a l m o l 6 : 5 7 , 1 9 8 6 .
3 3 . S t r o n d M H , N e w m a n N M , K c l t n e r J L * G a y A J — A b d u c t i n g n y s t a g m u s i n t h e m e d i a l l o n g i t u d i n a l f a s c i c u l u s ( M L F ) s y n d r o m e - i n t e m u c l e a r o p h t h a l m o p l e g i a ( I N O ) . A r c h O p h t h a l m o l 9 2 : 2 , 1 9 7 4 .
3 4 . S u W P D , S c h r o e t e r A D , P e r r y H O , P o w e l l F C — H i s t o p a t h o l o g i c a n d i m m u n o p a t h o l o g i c s t u d y o f p y o d e r m a g a n g r e n o s u m . J C u t P a t h o l 1 3 : 3 2 3 , 1 9 8 6 .
3 5 . W e i n e r L P , K o n i g s m a c k B W , S t o l l J , M a g l a d e r y J W — H e r e d i t a r y o l i v o p o n t o c e r e b e l l a r a t r o p h y w i t h r e t i n a l d e g e n e r a t i o n : r e p o r t o f a f a m i l y t h r o u g h s i x g e n e r a t i o n s . A r c h N e u r o l 1 6 : 3 6 4 , 1 9 7 6 .
3 6 . W i l s o n S A K — C a s e no 3 , p r e s e n t e d a t t h e c l i n i c a l m e e t i n g o f t h e N e u r o l o g i c a l S o c i e t y o f t h e U n i t e d K i n d g o m , o n M a r c h 2 9 , 1 9 0 6 . B r a i n 2 7 : 2 9 8 , 1 9 0 6 .
