Wall-eyed bilateral internuclear ophthalmoplegia syndrome from a brainstem haemorrhage

Wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) syndrome is characterized by bilateral internuclear ophthalmoplegia (INO) with alternating exotropia. The syndrome is a rare variant of INO, and was first reported in 1974 in a patient with vascular lesion.1,2 WEBINO has many distinct clinical findings, with the most common being primary gaze exotropia, adduction deficit, nystagmus of abducting eye, and vertical gaze-evoked nystagmus.3 And whilst the pathogenesis of WEBINO remains uncertain, the involvement of bilateral medial longitudinal fasciculus (MLF) is known to play an important role.4 WEBINO is most often caused by a demyelinating process or ischemic stroke. Less common causes include trauma, brainstem tumour, and hydrocephalus.5 Additionally, there are several case reports of WEBINO caused by vasculitis in patients with systemic lupus erythematosus (SLE).6 Here, we report a patient with brainstem haemorrhage (pontine bleeding with spread into the mesencephalon) that led to WEBINO syndrome. A 55-year-old woman with history of uncontrolled hypertension (HTN) was referred into our hospital with loss of consciousness