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A 52-year-old man presented with sudden onset of vertical diplopia, limited vertical gaze (figure 1), vertical oscillopsia, taste changes and lip numbness. His family had noted left-sided facial changes, with flattening of the nasolabial fold (figure 2). He had no significant medical or family history. He worked as a bus driver, drank 21 units of alcohol per week and had a smoking history of 9 pack-year.
On examination, there was subtle unilateral upper motor neurone facial weakness. He had normal visual acuity, colour vision, visual fields and fundus examination. Eye movement examination showed completely absent voluntary up and down gaze, both saccadic and pursuit, with some vertical gaze on the doll’s head manoeuvre. Pupil examination identified loss of pupillary contraction to light with …
EP and HJK are joint first authors.
EP and HJK contributed equally.
Contributors I can confirm that the authors of this manuscript have been involved in the planning, conduct and reporting of this case.
Funding MGT is supported by the NIHR (CL-2017-11-003) and the Ulverscroft Foundation.
Disclaimer The sponsor or funding organisation had no role in the design or conduct of this research.
Competing interests None declared.
Provenance and peer review Not commissioned. Externally peer reviewed by Ed Margolin, Toronto, Canada, and Tom Hughes, Cardiff, UK.