Etiology and surgical management of horizontal pontine gaze palsy with ipsilateral esotropia

Introduction: An esotropia ipsilateral to a horizontal pontine gaze palsy has been infrequently reported. We discuss the etiology and review the surgical management of this ocular motility defect. Methods: Four patients with radiographically documented dorsal pontine lesions and persistent horizontal gaze palsy with esotropia ipsilateral to the gaze palsy were treated. In each patient, the esotropia was present in attempted primary gaze, producing symptomatic diplopia. An anomalous face turn was required to attain single binocular vision. Results: All 4 patients underwent surgical correction to alleviate the anomalous head position and diplopia. Bilateral, asymmetric surgery was required to achieve a long-term successful result. Single binocular vision in the primary position with elimination or marked improvement of the compensatory head posture was initially achieved in all 4 patients. One patient, who had not undergone asymmetric strabismus surgery to reconcile incomitance produced by the esotropia, rapidly developed a residual esotropia. Conclusions: Ophthalmologists should recognize that concurrent esotropia may occur in patients with horizontal pontine gaze palsy. Single binocular vision in the primary position, an expanded binocular visual field, and alleviation of a compensatory head position are achievable with strabismus surgery.