Tonic downward and inward ocular deviation ipsilateral to pontine tegmental hemorrhage

A 61-year-old man presented with coma and left hemiparesis. He was found to have tonic downward and inward deviation of the right eye, and a right lateral gaze palsy. He also had occasional downward bobbing movements of the right eye, and a partial bilateral upgaze paresis. CT showed a right pontine tegmental hemorrhage extending to the ipsilateral midbrain. Tonic ocular downward and inward deviation associated with pontine tegmental hemorrhage may be due to irritation of mesencephalic downgaze and convergence centers by rostral extension of the hematoma. Although 'eyes seeming to peer at the tip of the nose' is characteristic of thalamic hemorrhage, it may also be seen secondary to pontine tegmental hemorrhage.