Case number: 134

La balade des yeux

Author: Catherine Maurice*, Priya Durairaj*, Hatem Krema, Warren P Mason, Felix Tyndel (*equal contribution)

A 47 year-old man presented with 3 months of ptosis and diplopia.

He had had an anaplastic astrocytoma of the left temporal lobe diagnosed 3.5 years prior, initially treated with partial surgical resection followed by chemoradiation and temozolomide, completed 22 months prior.  He had been clinically and radiologically stable, with post-treatment MRI showing a residual hyperintense FLAIR lesion of the left occipital, temporal, insular and anteroinferior frontal lobes. A medial left uncal deviation with minimal mass effect on the left cerebral peduncle was seen, stable for 2. 5 years.

He first noticed intermittent, painless binocular diplopia a few days before bilateral cataract surgery,  followed ten days later by a rapidly progressive right ptosis, without other neurologic symptoms.

Visual acuity was 20/70 OD and 20/40 OS. Fundoscopy was normal and visual fields were full. Pupils were equal and reactive to light. Eye movements are shown. Neurologic examination was otherwise normal.


Here is a video of his eye movements too:

Question: where and what do you think the problem is? Send your answer to us! (Jason Barton)

View Diagnosis

The neuro-ophthalmologic examination showed bilateral partial oculomotor nuclei palsies sparing the pupils. Based on this and the clinical context, the differential diagnosis included tumor recurrence or myasthenia gravis.  Two brain MRIs including thin-slice sections of the posterior fossa found no brainstem or cavernous sinus lesions but an MR scan 4 months later revealed gliomatosis not only of the temporal lobes but also involving midbrain and pons, mandating chemotherapy.

case134MRI1 case134MRI2 case134MRI3

Based on the MRI results, this is likely bilateral partial nuclear lesions sparing Edinger-Westphal nucleus located rostrally.  The oculomotor nucleus is composed of subnuclei, the levator palpabrae subnucleus being located caudally in the midline, and the Edinger Westphal nucleus more rostrally.  In our case, there was likely partial involvement of the dorsal, intermediate and ventral subnuclei, responsible for the inferior rectus, inferior oblique and medial rectus muscles respectively.  This was likely due to infiltration by an astrocytoma.