Wall-Eyed Monocular Internuclear Ophthalmoplegia (WEMINO) and Millard-Gubler Syndromes in a Patient with Isolated Pontine Infarction: Topographic, Oculomotor, and Radiological Analysis of Two Very Uncommon Conditions

Abstract

The syndromes of wall-eyed monocular internuclear ophthalmoplegia and Millard-Gubler are very rare clinical complexes commonly caused by pontine infarction, hemorrhage, or tumors that compromise the paramedian tegmentum, medial longitudinal fascicle, and the basis pontis. We present the case of a 58-year-old female with an isolated pontine infarction characterized by acute vertigo, sudden horizontal diplopia due to ipsilateral internuclear ophthalmoplegia with exotropia, facial palsy and contralateral hemiparesis. This report analyzes, theorizes, and emphasizes the correlation between these atypical neurological findings, the pontine anatomy, and magnetic resonance imaging; encouraging the clinician to make expeditious diagnoses using the bedside skills and a high-quality oculomotor clinical examination. The phenotype and simultaneity of both syndromes makes this case a didactic exercise for the topo-diagnosis based on the neurology of eye movements, the intrinsic physiology of the pons, and the pathways that emerge or project towards it.

Keywords

• WEMINO
• Internuclear ophthalmoplegia
• Millard-Gubler syndrome
• Pontine infarction
• Exotropia