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TEACHING NEUROIMAGE
Year : 2019  |  Volume : 22  |  Issue : 4  |  Page : 490
 

Vertical diplopia: Skew deviation and medullary lesion


Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India

Date of Submission27-Jan-2019
Date of Acceptance28-Feb-2019
Date of Web Publication25-Oct-2019

Correspondence Address:
Dr. Arunmozhimaran Elavarasi
Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aian.AIAN_46_19

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How to cite this article:
Elavarasi A, Mani B. Vertical diplopia: Skew deviation and medullary lesion. Ann Indian Acad Neurol 2019;22:490

How to cite this URL:
Elavarasi A, Mani B. Vertical diplopia: Skew deviation and medullary lesion. Ann Indian Acad Neurol [serial online] 2019 [cited 2019 Nov 17];22:490. Available from: http://www.annalsofian.org/text.asp?2019/22/4/490/257654



   Case Report Top


A 38-year-old female developed sudden onset vertical diplopia on looking upward and towards the left side. She had left hyperopia, neck deviation to the right, left eye incyclotorsion, and right eye excyclotorsion [Figure 1]. The skew was incomitant (left hyperopia more on left gaze and less on right gaze). Alternate cover test did not reveal corrective ocular counter roll. Skew deviation is vertical ocular misalignment because of the supranuclear gaze pathway lesion.[1] It may be comitant, incomitant, or alternating. It is associated with lesions in the posterior fossa. In some cases, the condition may mimic trochlear nerve palsy. The supine upright test helps differentiate these two conditions.[2] In our case, the patient had a clear history of diplopia on looking to left and upwards as well as reduction in diplopia (reduced distance between true and false image) by upto 80% on lying down. She had no vascular risk factors. Magnetic resonance imaging showed a FLAIR hyperintense lesion in the medulla on the right side [Figure 2]. CSF examination was normal. Oligoclonal bands were negative. A provisional diagnosis of demyelinating plaque was made. She was treated with intravenous pulse methylprednisolone, followed by oral prednisolone with significant improvement.
Figure 1: Examination revealed left eyelid retraction, left hyperopia with ocular tilt, and no nystagmus. (a-f) Rest of the neurologic examination was normal

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Figure 2: MRI revealed a FLAIR hyperintense lesion in the ventral right medulla

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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 initials 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.
Brodsky MC, Donahue SP, Vaphiades M, Brandt T. Skew deviation revisited. Surv Ophthalmol 2006;51:105-28.  Back to cited text no. 1
    
2.
Wong AMF. Understanding skew deviation and a new clinical test to differentiate it from trochlear nerve palsy. J AAPOS 2010;14:61-7.  Back to cited text no. 2
    


    Figures

  [Figure 1], [Figure 2]



 

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