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Wall-eyed bilateral INO in caudal midbrain lesion Description: This is a 30-yo-woman with the relatively acute onset of diplopia. There was a large angle exotropia, very subtle lag of the adducting saccades OD>OS, suggestive of bilateral INOs. This was best seen with rapid horizontal saccades, and a lesion involving bilateral MLFs in the caudal midbrain was demonstrated on MRI. There was also upbeat nystagmus in upgaze which is a typical finding in bilateral MLF lesions as some of the fibers responsible for vertical gaze holding travel through the MLF. Author: Daniel R. Gold, D.O.; Departments of Neurology, Ophthalmology, Neurosurgery, Otolaryngology – Head & Neck Surgery The Johns Hopkins School of Medicine. Rights: This video is part of the NOVEL Exam Collection in NOVEL, the Neuro-Ophthalmology Virtual Education Library. Please cite the source when using this video. NOVEL.utah.edu Copyright Daniel Gold 2016. For further information regarding the rights to this collection, please visit http://library.med.utah.edu/NOVEL/about/copyright