Topic 14. Gaze disturbances and their localizing significances

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A gaze disturbance means a problem of conjugate eye movement: both eyes are supposed to move together in the same direction, but the patient cannot direct both eyes normally to one side or vertically.

This topic is highly localizing. In the exam, the key is to distinguish:

Problem	Eye movement pattern	Diplopia?	Main localization
Gaze disturbance	Both eyes fail to move together in one direction	Usually no diplopia	Supranuclear/cortical or brainstem gaze centers
Ocular motor palsy	One eye does not move properly → eyes become disconjugate	Usually diplopia	III, IV, VI nucleus/nerve, neuromuscular junction, muscle/orbit
Internuclear ophthalmoplegia	Disconnection between abducens and oculomotor nuclei	Often diplopia/oscillopsia	Medial longitudinal fasciculus

So the examiner usually wants: Is it conjugate or disconjugate? Is it horizontal or vertical? Is it cortical, pontine, mesencephalic, or medial longitudinal fasciculus?

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