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A 67-year-old man was found comatose after subarachnoid hemorrhage from rerupture of a previously clipped anterior communicating artery aneurysm. He had no motor response and no eye opening in response to pain. Corneal, cough, and pupil reflexes were intact. Initially he had forced downward gaze with small reactive pupils that evolved in a matter of hours to an extreme exotropia of both eyes that persisted for days (Figure 1). Oculovestibular responses to cold caloric stimulation were absent.
Jacob JT, Burns JA, Dupont SA, Lanzino G, Wijdicks EF. Wall-Eyed Bilateral Internuclear Ophthalmoplegia After Ruptured Aneurysm. Arch Neurol. 2010;67(5):636-637. doi:10.1001/archneurol.2010.60