Neuro-Optometric Treatment of Wall-eyed Bilateral Internuclear Ophthalmoplegia (WEBINO)

Background Wall-eyed Bilateral Internuclear Ophthalmoplegia (WEBINO) is an ocular motility disorder characterized by bilateral exotropia in primary gaze, bilateral internuclear ophthalmoplegia with defective adduction of both eyes and nystagmus of the contralateral eye on abduction. Convergence is impaired because the lesion is in the midbrain. The etiology of WEBINO includes demyelination, stroke, and tumors, but midbrain infarction is the most common.1 Although extraocular muscle surgery and botulinum toxin injections are typically used for management2 of WEBINO, neuro-optometric rehabilitation can be utilized as an effective option to improve vision. Case Report A 39-year-old Caucasian male with non-traumatic brain injury due to left intraparenchymal hemorrhage from stroke, presented with WEBINO and multiple vision signs and symptoms, including blurred vision, alternating exotropia, diplopia, and strabismus. During the previous 8 months, he participated in physical therapy, occupational therapy, and speech therapy. He had difficulty participating in his therapies due to his vision issues. Single vision distance lenses were prescribed to improve vision clarity and 6 in-office neuro-optometric rehabilitation sessions were administered to improve range of motion of eye movements and to improve vision. Conclusions Neuro-optometric rehabilitation utilizes a systematic approach to treating patients with binocular vision dysfunction, while integrating cognitive, motor, and sensory skills. Prognosis is optimized with an individualized approach. Top-down processing stimulates the brain in a more direct way to elicit plasticity-mediated motor relearning.3 In this case, extraocular muscle surgery and botulinum toxin injections were not optimal choices and neuro- optometric rehabilitation was utilized to manage WEBINO and improve quality of life.