Intended for healthcare professionals

Endgames Picture Quiz

Sudden onset double vision

BMJ 2014; 348 doi: (Published 19 May 2014) Cite this as: BMJ 2014;348:g3286
  1. Nicholas R Plummer, academic foundation year 1 doctor,
  2. Thomas Thorp, specialty registrar, elderly medicine,
  3. Sulaiman Sultan, consultant cerebrovascular physician
  1. 1Acute Stroke Unit, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston PR2 9HT, UK
  1. Correspondence to: N R Plummer nickplummer{at}

An 83 year old woman was admitted to the acute stroke unit with sudden onset double vision that had lasted for three hours. She had a medical history of monoclonal gammopathy of uncertain significance and atrial fibrillation, for which she was not receiving anticoagulation because of an adverse reaction to warfarin. She had no history of transient ischaemic attack or stroke. She had diplopia only when looking through her right. On examination she was unable to adduct her left eye, with nystagmus in her right eye when she attempted to do this. Her neurological examination was otherwise normal. Computed tomography of the head on admission was normal, as was magnetic resonance imaging of the head, which was requested the next day. Figure 1 shows T2 weighted (A) and diffusion weighted (B) sequences at the level of the upper pons.


  • 1. What is this eye lesion called, and what is its pathological basis?

  • 2. What does the magnetic resonance image show?

  • 3. What are the differential diagnoses?

  • 4. How should this condition be managed further?


1. What is this eye lesion called, and what is its pathological basis?

Short answer

Left internuclear ophthalmoplegia. It is caused by impairment of conjugate eye movements owing to injury to the medial longitudinal fasciculus on the side of the impaired eye.

Long answer

Internuclear opthalmoplegia (INO) is caused …

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