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Skew deviation is likely encountered clinically more often than previously thought. Cerebellar causes of skew deviation appear to be the rarest cause and should be considered by clinicians when encountering patients with findings consistent with skew deviation.This case report describes an undiagnosed, asymptomatic skew deviation in an established glaucoma patient returning for routine follow-up. Appropriate diagnosis and subsequent neuroimaging identified a chronic ischemic cerebellar infarction.A 72-year-old man presented for a routine glaucoma follow-up examination. Cover test revealed a 10-prism diopter left hypertropia, which worsened in right gaze and left head tilt. Double Maddox rod testing showed 5° excyclotorsion of the right eye and no torsion in the left eye. Upright-supine testing was positive. Given the patient's noticeable right head tilt, left hypertropia, increased excyclotorsion of his lower eye, and positive-upright test, the patient was diagnosed with a skew deviation. Brain MRI revealed a chronic, undiagnosed cerebellar ischemic infarction, a known cause of skew deviation and the associated ocular tilt reaction.It can be challenging to identify skew deviations and their underlying causes. When clinically encountering a vertical deviation, appropriate tests (cover-uncover test, Parks-Bielschowsky three-step test, ocular torsion testing, and upright-supine test) are imperative to help make the correct diagnosis. Neuroimaging can then be pursued in hopes of identifying the underlying cause.

Disorders of ocular torsion can occur in acquired neurologic conditions such as trochlear nerve palsies and skew deviations. 1-6 Ocular torsion is measured in degrees and is denoted with positive v...

Trochlear nerve (CN IV) nuclei are located in the midbrain at the level of the inferior colliculi and innervate the superior oblique extraocular muscles.1 As they are the only cranial nerves to exi...

Alport syndrome is an inherited X-linked collagen IV disorder (80-85% cases) associated with renal failure (99%), hearing loss (82.5%), and ocular findings (44-81%), most commonly involving the cor...

Foville syndrome is a well‐recognised clinical entity and is defined as a caudal dorsolateral pontine syndrome with the following ipsilateral clinical findings: facial hemi‐hypoesthesia, ocular abd...

Significance A rare case of bilateral horizontal gaze palsy with intact vertical gaze eye movements and largely intact vestibulo-ocular reflex is presented owing to demyelinating lesions of the patient's bilateral paramedian pontine reticular formations and left infranuclear abducens nerve from the patient's recently diagnosed multiple sclerosis. Purpose The purpose of this study was to report on a rare case of bilateral horizontal gaze palsy from a supranuclear lesion in a patient with a recent diagnosis of multiple sclerosis. Case report A 43-year-old African American woman presented urgently for evaluation of her inability to move her eyes into either horizontal gaze. Vertical conjugate movements remained intact, as did three of four extraocular muscles with horizontal vestibulo-ocular reflex testing, suggesting a supranuclear palsy. Magnetic resonance imaging revealed two demyelinating lesions in her inferior pons, which spared her nuclear and internuclear horizontal gaze pathways, as well as three of four extraocular muscles of her infranuclear horizontal gaze pathway as evidenced by her largely intact vestibulo-ocular reflex. This suggested bilateral paramedian pontine reticular formation lesions (supranuclear) and a mild left abducens nerve palsy (infranuclear). Conclusions Close evaluation of extraocular motilities and a solid understanding of the supranuclear, nuclear, internuclear, and infranuclear components of the horizontal gaze pathway can help identify challenging gaze palsies when encountered in a clinical setting. Appropriate neuroimaging can then be performed with an emphasis on the suspected location of the lesion(s) based on the patient's clinical findings.

Trochlear nerve palsies and internuclear ophthalmoplegias are well documented neuro‐ophthalmological conditions.2017 However, cases of both of these conditions occurring together in the same patien...

Multiple myeloma is a neoplastic plasma-cell disorder resulting from malignant plasma cells in the bone marrow. It can cause a hyperviscosity syndrome secondary to the paraproteinaemia associated with the disease. The increased hyperviscosity can lead to retinal vein occlusions and other ocular problems that may challenge clinicians. In patients with multiple myeloma and hypertension and/or diabetes mellitus, retinal changes appear similar and changes due to one disease or the other may be difficult to determine. A 48-year-old white female presented to the clinic with a complaint of blurry vision in her left eye. A full comprehensive ocular examination revealed a central retinal vein occlusion presumably from the patient's history of hypertension, diabetes mellitus and hypercholesterolaemia. Further bloodwork revealed monoclonal protein in the patient's serum and an increased percentage of plasma cells in the bone marrow. She was diagnosed with monoclonal gammopathy of undetermined significance, part of the multiple myeloma disease spectrum. She was referred to a retinal specialist for initiation of intravitreal injections of anti-vascular endothelial growth factor. Multiple myeloma has been implicated in younger patients as an underlying cause of retinal vein occlusions. Multiple myeloma should be considered as a differential diagnosis in young patients with retinal vein occlusions, even if other risk factors for venous occlusion like hypertension, diabetes mellitus and hypercholesterolaemia are present. Timely referral to the patient's primary care physician and haematologist is important for appropriate treatment and control of underlying systemic conditions.

Bacillus thuringiensis is a Gram‐positive, rod‐shaped (bacillus), soil‐dwelling bacterium capable of forming spores and producing crystal proteins/toxins that are used worldwide as insecticides.201...