Vertical gaze palsy associated with bilateral ptosis following right putaminal hemorrhage

Previous reports suggest that right hemispheric lesions may produce a variety of disorders in eye opening, including bilateral eyelid ptosis. More recently, bilateral ptosis and a severe deficit of upward gaze while preserving the downward gaze have been reported in patients with right hemispheric infarction. In the present report, we describe 2 patients who showed downward gaze palsy in addition to upward gaze palsy, accompanied by bilateral ptosis following right putaminal hemorrhage. The 2 patients displayed acute onset of similar ocular manifestations, such as difficulty in eye opening, upward and downward gaze palsy, and conjugate horizontal deviation in addition to left hemiparesis. The principal cause of difficulty in eye opening was considered to be bilateral ptosis. Computed tomography performed on admission revealed a moderate-sized hematoma in the right putamen. There was no evidence of midbrain involvement. These ocular symptoms were restored within a few weeks after the onset of stroke. The ocular manifestations noted in our patients suggest that the descending pathways arising from the supranuclear centers to the midbrain, which control vertical movement of the eyes and the eyelids, may be impaired by putaminal hemorrhage. To our knowledge, this is the first report of such ocular manifestations in the right hemispheric lesion.