Motility Disturbances

A 27-year-old healthy man presented for neuro-ophthalmologic evaluation for recurrent vertical binocular diplopia. In 1982, he had a minor blow to the head, and 12 days later he sustained vertical binocular diplopia, worse on downgaze, without ever having diurnal variation. His sense of taste was also transiently diminished on the left side of his tongue. The examining neurologist noted 1 mm-2 mm of ptosis OD; the rest of the examination was normal. A CT scan showed a questionable lesion in the left cerebral peduncle, displacing the posterior third ventricle to the right. A spinal tap was normal, and all diplopia resolved over the next 2 months. Three years later, he had a visual abnormality that was hard for him to describe, but he knew that closing either eye made it better. This resolved over 2 months. Three years later, overt diplopia ensued. His examination showed acuity 20/20 OU; pupils 6 mm OU, 8.5 OS, all due to lower lid ptosis; motility: left face turn, 3+ underaction left inferior rectus, 1+ overaction left superior rectus. Neurologic examination was otherwise normal. A Tensilon test did not elicit change in his examination. The MRI showed a hemorrhagic lesion in the region of the inferior rectus subnucleus. Cerebral angiography was normal. This was felt to be a recurrent bleed from a cryptogenic arteriovenous malformation. Pair with Images 91_72, 91_73, 91_75, 91_75, and 91_76