Traumatic bilateral internuclear ophthalmoplegia with plus syndrome

A young man in his 20s sustained head and body injuries after a fall from a height, 1 year ago for which he received emergency medical and surgical intervention. A month after the trauma, he noticed outward deviation of the right eye intermittently but did not experience diplopia. On examination, he had a bilateral adduction deficit, bilateral abduction nystagmus and a bilateral vertical nystagmus. The MRI (plain) showed an old haematoma with haemosiderin staining of the posterior midbrain and pons (extending to the bilateral medial longitudinal fasciculi). The patient was managed conservatively and was followed up closely. The present case describes bilateral internuclear ophthalmoplegia presenting subtly (without manifest exotropia or accompanying diplopia); hence, the condition remained undiagnosed. Though internuclear ophthalmoplegia (INO) due to demyelinating disease, ischaemia and infection may have a good prognosis; INO due to traumatic haemorrhage with chronic haematoma formation may take time to recover or become irreversible.