Post-traumatic Wall-eyed Bilateral Internuclear Ophthalmoplegia Like Syndrome with Bilateral Trochlear Nerve Palsy: A Diagnostic Challenge

Internuclear ophthalmoplegia (INO) is due to lesion in median longitudinal fasciculus commonly seen in multiple sclerosis or ischemic brain infarct. It is characterized by ipsilateral adduction deficiency, contralateral abduction nystagmus, and intact convergence. We present a rare case of posttraumatic wall-eyed bilateral INO (WEBINO) like syndrome with bilateral trochlear nerve palsy. A 45-year-old male referred with complaints of sudden onset outward deviation of eyes and binocular diplopia, following head injury 15 days back. Radiological investigations revealed no abnormality. A diagnosis of bilateral WEBINO like syndrome with bilateral trochlear nerve paralysis was made and neurology reference was advised. Patient improved with medical management over 1 month. This case report highlights the importance of a thorough examination in a trauma case. Furthermore, it is important to highlight these findings to create awareness among ophthalmologist and neurologist who may come across similar clinical picture while examining a trauma case. In posttraumatic WEBINO, associated trochlear nerve palsy is often overlooked. A meticulous examination of cranial nerves is mandatory in any case of head injury.