Acute hydrocephalus is a common cause of the Parinaud dorsal midbrain syndrome.^1,2 Most patients with this condition improve either immediately following treatment of the hydrocephalus or within a few months,¹ and it is generally assumed that those who do not do so have no potential for subsequent improvement. I recently evaluated a patient whose upward gaze spontaneously improved 4½ years after treatment of trauma related hydrocephalus.

Case report

A 23 year old Asian man was in his usual excellent general and ocular health until October 2000, when he was struck by a car while walking across the street. He was taken to a local hospital where he was found to have extensive injuries, including bilateral subdural and epidural haematomas. He also had evidence of increased intracranial pressure and required an emergency cranial decompression. Postoperatively, he was evaluated by a neuro-ophthalmologist who noted that the patient’s only ocular disturbance was a mild left trochlear nerve paresis. The paresis resolved within about 3 weeks.

About 6 months after the injury, the patient developed severe headaches and double vision. He was evaluated by the same neuro-ophthalmologist who had evaluated him previously. He noted that the patient now had a severe dorsal midbrain syndrome characterised by lack of elevation of either eye above the midline associated with an exotropia of 25–30 prism dioptres at distance and …