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Ocular tilt reaction and internuclear ophthalmoplegia associated with venous sinus thrombosis: an unusual case
  1. C Gerth,
  2. J R Buncic
  1. Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children and The University of Toronto, Toronto, Canada
  1. Correspondence to J Raymond Buncic University of Toronto and The Hospital for Sick Children, Department of Ophthalmology and Vision Sciences, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; ray.buncic{at}sickkids.ca

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We report a child who developed a head tilt and unusual oculo-motor findings following otitis media with adjacent intracranial venous sinus thrombosis, progressive worsening of papilloedema with subsequent retinal nerve fiber layer (RNFL) and optic nerve atrophy and visual loss.

Case report

A 11-year-old previously healthy girl presented to the emergency department with an acute history of vomiting, neck and back pain, diplopia and photophobia after a 14-day unsuccessful treatment for bilateral otitis media.

Her general and neurological assessment was normal except for bilateral optic disc oedema, reduced hearing in the right ear and tenderness of her posterior neck. Visual acuity was 6/6 ou sc. Cerebral CT performed immediately after initial presentation revealed right internal jugular vein, sigmoid and transverse sinus thrombosis (figure 1). The patient was hospitalised and treated with anticoagulation, intravenous antibiotics and analgesics. A lumbar puncture was not done because of her anticoagulated state. Detailed screening for hypercoagulopathic risk factors was negative.

Figure 1

Saggital and coronal CT sections show a thrombus within the right jugular vein extending to the sigmoid and transverse sinus (arrowheads), which are expanded and dilated.

The patient deteriorated generally over the next 2 weeks and was generally unwell with headache and neck pain. She developed a left internuclear ophthalmoplegia (INO) with a left hypertropia and a right incomitant exotropia present in all directions but left gaze. Her papilloedema had worsened with new microinfarcts and hemorrhages overlying the discs, increased disc oedema, new haemorrhages in the papillomacular bundle, relative pallor of the right disc and some macular oedema. These signs were interpreted as an indication of inadequately controlled increased intracranial pressure, and treatment with acetazolamide 500 mg TID was started. Reassessment on the following day showed signs of right head tilt (figure 2) with ipsilateral conjugate torsion of her fundi. The diagnosis of an ocular …

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