CASE-REVERSE detailed formats in_INO.pptx

Informal Communication: Casual, spontaneous exchanges.
Characteristics: Relaxed, less structured.
Example: Watercooler conversations.
Interpersonal Communication: Between individuals.
Characteristics: Personal, relational.
Example: Friendships, family interactions.

1. CASE-REVERSE INO
AASHISH KUMAR

2. PRESENTING COMPLAINTS
25 year old female, without any previous comorbidities, came with complaints of
throbbing headache since 3 days. 
It was insidious in onset, continuous, moderate in intensity, bitemporal in
location, without any aggravating/ relieving factors.
It was associated with diplopia since 3 days.
Past complaints of paresthesias in both arms since 3 months

3. GCS: E4V5M6
Pulse: 98/ minute, regular
Blood pressure: 128/116 mmHg
Pupils; B/l 3 mm, reactive to light
B/l lateral rectus palsy
Fundoscopy: B/l papilloedema +
EXAMINATION

4. Motor
system:
Tone normal
in all limbs
Power: 5/5 in
all limbs
Deep tendon
reflexes: B/l
biceps,
triceps,
supinator,
knee and
ankle jerks
2+.
Plantars: B/l
flexor
•No sensory/
cerebellar/
meningeal
involvement
EXAMINATION

6. COURSE IN HOSPITAL
Treated with LMWH, Mannitol and 3% NaCl infusions
Headache reduced, day 3 of Hospitalization examination of extra
ocular movements showed:

9. Repeat CT Brain showed increased ICP features
Anti cerebral odema measures were continued
On day 5 of hospitalization she complained of bilateral painless diminution of vision
Right Eye VA: hand movements perceived
Left Eye VA: Finger counting at 1 meter present
Fundus: Bilateral papillodema

11. In view of CVT with raised ICP and vision loss, optic nerve sheath fenestration was
offered
Patient went DAMA due to financial considerations

12. DISCUSSION
Lutz termed reverse INO a "posterior INO of LUTZ”, as he thought the
"posterior" supranuclear fibers traveled to the lateral rectus muscle.

Kommerell suggested the more specific term “INO of abduction“
“Reverse INO” or Pseudoabducens palsy”

14. ABduction limitation due to abducens weakness.
It is debated if this is due to pre-nuclear, nuclear, fascicular or internuclear lesions of the
abducens nerve
Localization includes PPRF, pontine MLF, pre-nuclear rostral pons, abducens fasiculus,
and midbrain
Contralateral ADduction nystagmus. Etiology is unclear but could be due to increased
signaling to the yoked contralateral medial rectus after ipsilateral lateral rectus
weakness, as proposed in reverse for a typical INO
Thomke F, Hopf HC, Kramer G. Internuclear ophthalmoplegia of abduction: clinical and
electrophysiological data on the existence of an abduction paresis of prenuclear origin. J
Neurol Neurosurg Psychiatry 1992;55:105-11
Bogousslavsky J, Regli F, Ostinelli B, Rabinowicz T. Paresis of lateral gaze alternating
with so-called posterior internuclear ophthalmoplegia. A partial paramedian pontine
reticular formation-abducens nucleus syndrome. J Neurol. 1985;232(1):38-42.

15. POSSIBLE MECHANISMS
1 Failure to relax medial rectus muscle due to a midbrain lesion
2 Interruption of the projection of internuclear neurons to the contralateral abducens nucleus via
the MLF due to a midbrain lesion
3 Lesions of the PPRF causing decreased activation of specific burst neurons or the abducting eye
Bijvank, J. A. N., Balk, L., Tan, H. S., Uitdehaag, B. M. J., van Rijn, L. J., & Petzold, A. (2016). A
rare variant of INO in multiple sclerosis: posterior INO of Lutz. Multiple Sclerosis, 22, 154-154

16. CAUSES
Stroke
Multiple sclerosis
Head trauma
Cerebral herniation
Infection (HIV, cysticercosis, syphilis, meningitis, sepsis, brucellosis)
Tumors
Post-surgical/-procedural
Brainstem hemorrhage
Vasculitis
Eyewiki

17. 1. Pseudo-INO: Myasthenia gravis and Guillain-Barré syndrome
2. INO Mimics:
-Idiopathic intracranial hypertension
-INO occurrence after placement of a fourth ventricle shunt
-2 case reports of orbital metastasis
Keane JR. Internuclear ophthalmoplegia: unusual causes in 114 of 410
patients. Arch Neurol. 2005 May;62(5):714-7.
Differential diagnoses:

18. CONCLUSION
Reverse INO is a rare phenomena
Pathophysiological basis is postulated, but not confirmed
Causes can be varied
Treatment depends on treating the underlying condition

19. THANK YOU