title: A case of double depressor palsy followed by pursuit deficit due to sequential infarction in bilateral thalamus and right medial superior temporal area.
abstract: BACKGROUND
  We present a unique case of a patient who suffered two rare events affecting the supranuclear control, first of the vertical and second of the horizontal eye movements. The first event involved bilateral thalamic infarcts that resulted in double depressor palsy. The second event occurred 1 year later and it involved supranuclear control of horizontal eye movements creating pursuit deficit.
  
  
  METHODS
  A 47-year-old male presented with complaints of diplopia upon awakening. He had atrial fibrillation, mitral valve regurgitation, aortic valve regurgitation, and a history of spleen infarction 1 year ago. His right eye was hypertrophic and right eye downgaze was limited unilaterally of equal degree in adduction and abduction. The patient was diagnosed with double depressor palsy of the right eye. Magnetic resonance imaging (MRI) of the brain showed an old infarction of the left thalamus, and diffusion MRI showed acute infarction of the right thalamus. The patient's daily warfarin dose was 2 mg and it was increased to 5 mg with cilostazol 75 mg twice a day. Seven weeks later, the patient's ocular movement revealed near normal muscle action, and subjectively, the patient was diplopia free. At follow-up 12 months later, the patient revisited the hospital because of sudden onset of blurred vision on right gaze. He was observed to have smooth pursuit deficit to the right side, and orthophoric position of the eyes in primary gaze. MRI of the brain showed an acute infarction in the right medial superior temporal area.
  
  
  CONCLUSIONS
  The patient experienced very rare abnormal eyeball movements twice. This case highlights the importance of evaluating vertical movement of the eyes and vascular supplies when patients present with depressor deficit and supports the theory of a supranuclear function in patients who present with pursuit deficit.
authors.affiliation: Department of Ophthalmology, Gyeongsang National University Changwon Hospital, School of Medicine, Gyeongsang National University, 121, Samjeongja-ro, Changwon, Gyeongsangnam-do, 51476, South Korea. pearlksj@gmail.com.
authors.forename: Su Jin
authors.initials: SJ
authors.lastname: Kim
authors.affiliation: Department of Ophthalmology, Maryknoll Medical Center, 121 Junggu-ro, Jung-gu, Busan, 48972, South Korea.
authors.forename: Myeong In
authors.initials: MI
authors.lastname: Yeom
authors.affiliation: Department of Ophthalmology, School of Medicine, Kosin University, #34 Amnam-dong, Seo-gu, Busan, 602-702, South Korea.
authors.forename: Seung Uk
authors.initials: SU
authors.lastname: Lee
mesh_terms: D020520:Brain Infarction / Q000150:complications*; D004172:Diplopia / Q000209:etiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D015835:Ocular Motility Disorders / Q000209:etiology*; D013494:Supranuclear Palsy, Progressive / Q000209:etiology*; D013788:Thalamus / Q000098:blood supply*
keywords: Artery of Percheron; Bilateral thalamic infarction; Double depressor palsy; MST; Medial superior temporal area; Monocular depression palsy; Parieto–temporal–occipital junction infarct; Pursuit deficit