LAUSR

A 69-year-old man with hypertension, diabetes, and chronic atrial fibrillation on apixaban developed acute onset dizziness and diplopia. Initial neurological examination was remarkable for a right-sided internuclear ophthalmoplegia (INO) and a mild left upper motor neuron (UMN) facial palsy. Direct and indirect pupillary light reflexes were normal, visual fields were full to confrontational testing, and there was no ptosis. Initial non-contrast CT and MRI of the head revealed chronic white matter ischemic changes. Twenty four hours later his diplopia worsened, and interval examination revealed an exotropic bilateral INO (EBINO) with slow abducting saccades during fast eye movements [Video 1]. Vertical gaze and convergence were normal, and no up beating nystagmus were appreciated. The left-sided facial palsy was confirmed by the patient to be chronic. The remainder of neurological examination was unremarkable. A repeat MRI of the brain demonstrated an acute ischemic infarct only in the medial dorsal pons, and chronic microvascular changes [Fig. 1]. Wall-eyed INO Hereafter, we will describe the condition with the pejorative phrase EBINO. Classically the patient with EBINO