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| CASE REPORT |
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| Year : 1995 | Volume
: 43
| Issue : 1 | Page : 31-32 |
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Reverse parinaud's syndrome due to pineal tumour
Vimala Menon, Sudarshan Khokhar, Radhika Tondan
From Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
Correspondence Address:
Vimala Menon
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi 110 029
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 8522369 
How to cite this article:
Menon V, Khokhar S, Tondan R. Reverse parinaud's syndrome due to pineal tumour. Indian J Ophthalmol 1995;43:31-2 |
Compared to paralysis of upward gaze, paralysis of downward gaze is rare. In patients with pinealoma, upward gaze is mostly involved with relative sparing of downward gaze.[1] Downgaze palsy refers to an impairment of conjugate eye movements downward on command or in pursuit of a target, with proportionately little involvement of horizontal movements. In very rare cases, downgaze palsy may be the only disorder.[2],[3]
| Case report | |  |
A-30 year-old male who had undergone surgery for a pineal gland tumour was referred to our neuro-ophthalmology clinic for ophthalmologic evaluation for complaints of blurred vision and inability to move the eyes downward.
Ophthalmologic examination revealed a best-corrected visual acuity of 6/6 in both eyes. He had chin depression and bilateral upper lid retraction. The pupils were not reactive to light, but reactive to near-reflex. There was total loss of downward eye movements both on command and pursuit. Upward and horizontal eye movements were within normal limits. There was a mild convergence insufficiency. Fundus was normal in both eyes.
On neurologic examination, his higher functions, motor and sensory systems were within normal limits. All cranial nerves were normal. His preoperative magnetic resonance imaging scan demonstrated a solid hyperdense mass [Figure:1],[Figure:2] in the posterior third ventricle and pineal region compressing the quadrigeminal cistern and causing obstructive hydrocephalus. He had undergone ventriculoperitoneal shunt followed four days later by surgical removal of the tumour which was diagnosed as a pineal gland dysgerminoma on histopathology. Postoperatively, he has been given a course of chemotherapy followed by radiotherapy.
The patient's main complaint when he presented to our neuro-ophthalmology clinic was discomfort in maintaining chin depression to overcome the disadvantage of his downgaze palsy. Base down prisms were prescribed for both eyes to help him in his routine activities.
| Discussion | | |
Compared to paralysis of upward gaze, downward gaze palsy affects the patient's daily life adversely. Downgaze palsy can be quite incapacitating, necessitating a head posture in the form of chin depression to have comfortable vision. However, even this head posture may not be adequate to enable the patient to fixate objects. This particular patient, was able to manage with great difficulty on adapting chin depression. Base down prisms eliminated his head posture and relieved him of his symptoms.
Parinaud's syndrome, which is usually characterised by the triad of upgaze palsy, weakness of convergence and pupillary hyporeflexia may sometimes be associated with a convergence or retraction nystagmus and downgaze weakness.[2] The lesion in these cases is located in the anterior portion of the midbrain in the tectal or pretectal area, where the vertical gaze centre is situated.[2],[4],[5] The term, "reverse Parinaud's syndrome" is used for downgaze palsy associated with convergence paralysis and pupillary areflexia.[2] The patient in this case report presented with a similar clinical picture and the magnetic resonance imaging revealed a lesion of the pineal gland. He had undergone surgery for the pineal body tumour which was histologically confirmed as a malignant dysgerminoma. Very few cases of reverse Parinaud's syndrome are reported in the literature.[2],[3]In these reported cases the aetiology described was either trauma or a vascular lesion in the anterior mesencephalon. In the presence of downgaze palsy, lesions of the anterior mesencephalon should be kept in mind. The case presented here is of specific interest because it is rare for a pineal tumour to manifest as a reverse Parinaud's syndrome.
| References | | |
| 1. | Pierrot-Deseilligny CH, Chain F, Gray E, et al. Parinaud's Syndrome. Brain 105:667-696, 1982.  |
| 2. | Cogan D. Paralysis of downgaze. Arch Ophthalmol 91:192-199, 1974. |
| 3. | Jacobs L, Anderson PJ, Bender MB. The lesion producing paralysis of downward but not upward gaze. Arch Neurol 28:319-323, 1973. |
| 4. | Walsh and Hoyt's Clinical Neuro-Ophthalmology, 4th ed., Vol. 2. Miller NR (Ed.). Baltimore, Williams and Wilkins, 1969, pp. 719-722. |
| 5. | Segarra JM. Cerebrovascular disease and behaviour: The syndrome of the mesencephalic artery. Arch Neurol 22: 408-418, 1970. |
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