Is it true that with gaze palsy, a patient cannot look in the direction of the lesion?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: December 13, 2025 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Gaze Palsy and Direction of Lesion: A Critical Clarification

No, this statement is incorrect—with gaze palsy and gaze preference, the patient typically CANNOT look AWAY from the side of the lesion, not toward it. 1

Understanding the Directional Relationship

The confusion arises from mixing two distinct concepts that have opposite directional relationships:

Gaze Palsy (Nuclear/Infranuclear Lesions)

  • With pontine/brainstem lesions affecting gaze centers, patients cannot look TOWARD the side of the lesion. 2, 1
  • A left pontine lesion affecting the left abducens nucleus produces a left horizontal gaze palsy, meaning the patient cannot move both eyes to the left. 2
  • The eyes deviate AWAY from the lesion side because the unopposed contralateral gaze center pushes the eyes in the opposite direction. 2
  • This represents a true structural inability to move the eyes in the affected direction, which cannot be overcome even with vestibulo-ocular reflex testing. 1

Gaze Preference (Supranuclear/Cortical Lesions)

  • With hemispheric cortical lesions, patients demonstrate gaze preference TOWARD the side of the lesion. 1
  • A right hemispheric stroke affecting the frontal eye fields causes the eyes to deviate toward the right (toward the lesion), because the left frontal eye field is unopposed and drives conjugate gaze to the right. 1
  • This is NOT a true palsy—the eyes can be moved past midline with vestibulo-ocular reflex testing, proving motor pathways remain intact. 1
  • The classic mnemonic: "The eyes look toward a cortical lesion (away from the paralyzed limbs) and away from a pontine lesion (toward the paralyzed limbs)." 1

The Critical Bedside Distinction

The vestibulo-ocular reflex (Doll's eyes maneuver) definitively distinguishes these entities:

  • Gaze preference: Eyes cross midline with head turning, indicating intact brainstem pathways. 1
  • Complete gaze palsy: Eyes remain fixed and cannot cross midline despite head turning, scoring 2 on the NIH Stroke Scale. 1
  • Partial gaze palsy: Eyes move partially but incompletely in the affected direction, scoring 1 on the NIH Stroke Scale. 1

Clinical Examples from Guidelines

Pontine Lesion (True Gaze Palsy)

  • A left pontine stroke affecting the abducens nucleus causes inability to look LEFT (toward the lesion side). 2
  • The patient presents with left 6th nerve palsy, left horizontal gaze palsy, left facial palsy, and right hemiparesis. 2
  • Both eyes cannot move to the left because the left abducens nucleus contains both motor neurons for the left lateral rectus AND interneurons coordinating conjugate horizontal gaze. 2

Hemispheric Lesion (Gaze Preference)

  • A right hemispheric stroke causes gaze preference to the RIGHT (toward the lesion). 1
  • This represents disruption of cortical control, not structural inability to move the eyes. 1
  • The vestibulo-ocular reflex successfully brings the eyes across midline, proving motor pathways are intact. 1

Common Pitfalls to Avoid

  • Do not confuse isolated 6th nerve palsy with horizontal gaze palsy. A 6th nerve palsy is an infranuclear problem affecting only one lateral rectus muscle, not a supranuclear gaze palsy affecting conjugate movements. 1
  • Do not assume all eye movement limitations are "palsies." Gaze preference is fundamentally different from gaze palsy and has different localization implications. 1
  • Always perform vestibulo-ocular reflex testing to distinguish between these entities in acute presentations. 1

References

1
Guideline

Gaze Palsy vs. Gaze Preference: Key Clinical Distinctions

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

2
Guideline

CNS Examination Format for Left Pontine Syndrome

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Related Questions

What is the appropriate management for a patient with downward gaze (inferior gaze palsy)?
How do I distinguish Internuclear Ophthalmoplegia (INO) from 6th cranial nerve palsy on physical exam?
What are the etiologies and management strategies for monocular ptosis and one and a half syndrome?
What is the management and treatment of one and a half syndrome?
What is the primary management approach for a patient with bilateral thalamic infarct presenting with vertical gaze palsy?
What is the recommended oral (po) dose of hydromorphone (Dilaudid) for an elderly patient with impaired renal function (eGFR of 30)?
Is coffee consumption safe during pregnancy?
What is the average rate of bone mass loss?
What are the treatment options for post nasal drip?
What is the recommended bridging strategy with Lovenox (enoxaparin) for patients on oral anticoagulants, such as warfarin, prior to surgery?
What is the best pharmacological treatment option for achieving long-term abstinence in someone with Alcohol Use Disorder (AUD)?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question