What is the treatment for Webino syndrome?

Treatment of WEBINO Syndrome

The primary treatment for WEBINO (Wall-Eyed Bilateral Internuclear Ophthalmoplegia) syndrome should be symptom-directed, focusing on improving binocular vision, controlling diplopia, and reducing tilt of the subjective visual vertical. 1

Understanding WEBINO Syndrome

WEBINO syndrome is characterized by:

• Bilateral adduction impairment
• Nystagmus of the abducting eye
• Primary gaze exotropia (wall-eyed appearance) 2, 3

Etiology

• Most commonly caused by lesions in the paramedian pontine tegmentum affecting the medial longitudinal fasciculus (MLF) 4
• Primary etiologies include:
  • Ischemic stroke (particularly in the midbrain tegmentum) 2, 5
  • Demyelinating diseases (particularly multiple sclerosis) 4
  • Less commonly: tumors or other mass lesions 3

Diagnostic Approach

A thorough neuro-ophthalmic evaluation should include:

• Complete sensorimotor evaluation with three-step test 1
• Careful assessment for other neuro-ophthalmic signs (Horner's syndrome, cranial nerve palsies, INO, nystagmus) 1
• Fundus examination to check for papilledema or optic atrophy 1
• Visual field testing to provide additional information on etiology 1

Treatment Algorithm

1. Initial Management

• Refer to neurology or otolaryngology specialists for evaluation of the underlying cause 1
• Initial treatment with prisms may help manage diplopia while waiting for possible recovery 1

2. Medical Treatment

• For demyelinating causes (such as multiple sclerosis):
  • Steroid pulse therapy may improve adduction of both eyes 4
  • Standard MS disease-modifying therapies should be considered for underlying disease

3. Interventional Options for Persistent Cases

• For cases that do not resolve spontaneously, consider:
  • Botulinum toxin injections 1
  • Prism therapy for persistent diplopia 1
  • Strabismus surgery for persistent large-angle exotropia 1, 6

4. Surgical Considerations

• Transposition surgery has been shown to effectively alleviate exodeviation in WEBINO patients 6
• Goals of surgery should be customized based on:
  • Degree of diplopia
  • Head tilt
  • Perceived tilting of the visual vertical 1

Special Considerations

Monitoring and Follow-up

• Regular follow-up with an ophthalmologist experienced in neuro-ophthalmology 1
• Orthoptists working under ophthalmologist supervision can assist in examination, diagnosis, and nonsurgical management 1

Prognosis

• Prognosis depends on the underlying etiology:
  • Stroke-related WEBINO may improve with time as the brain recovers 2, 5
  • MS-related WEBINO may persist despite treatment 4

Important Pitfalls to Avoid

1. Misdiagnosis: WEBINO can be confused with other causes of exotropia; careful assessment of adduction deficits and nystagmus is essential 3

2. Delayed Neuroimaging: Since WEBINO often indicates a brainstem lesion, prompt neuroimaging (preferably MRI) is crucial to identify the underlying cause 2, 5

3. Incomplete Evaluation: Always check for associated neurological signs that may help localize the lesion and determine etiology 1

4. Overlooking Treatable Causes: Some causes of WEBINO (such as demyelination) may respond to specific treatments, making timely diagnosis important 4