Pearls & Oysters: Looking up the anatomy of looking up

A 46-year-old Chinese man with diabetes mellitus, hypertension, and hyperlipidemia, developed sudden onset of vertiginous dizziness and diplopia that was worse on looking up. His symptoms were not preceded by any antecedent infections, neither was there any headache. Blood pressure on arrival in the Emergency Department was 145/95 mm Hg and his neurologic examination revealed bilateral upward gaze restriction (video on the Neurology(R) Web site at Neurology.org). There was voluntary lid retraction by the patient. The pupils were 3 mm bilaterally and reactive to light and accommodation, there was no ptosis or nystagmus, and no fatigability could be elicited. Apart from esophoria and pseudo-6th nerve palsy, the rest of the eye movements were normal. Other cranial nerves, motor, sensory, and cerebellar examinations were unremarkable. The vertical optokinetic reflex was intact and there was no tremor of the upper limbs. On forced eye closure, there was upward deviation of his eyes consistent with the Bell phenomenon. ECG did not show any atrial fibrillation or ischemic changes. The basic blood investigations were unremarkable. He was initially diagnosed with myasthenia gravis with frontalis overactivity and complex ophthalmoplegia by the admitting emergency physicians.