Potential conflict of interest: Nothing to report.
Intermittent disconjugate gaze: A novel finding in nonalcoholic steatohepatitis†
Article first published online: 23 MAR 2006
Copyright © 2006 American Association for the Study of Liver Diseases
Volume 43, Issue 4, pages 882–883, April 2006
How to Cite
Schartman, J. and Weinstein, J. (2006), Intermittent disconjugate gaze: A novel finding in nonalcoholic steatohepatitis. Hepatology, 43: 882–883. doi: 10.1002/hep.21134
- Issue published online: 23 MAR 2006
- Article first published online: 23 MAR 2006
We read with interest the letter by Al-Osaimi et al.1 Several points deserve clarification. The authors describe a motility disorder characterized by fluctuating exotropia that is “not typically present at all times.” Mitochondrial myopathies are characterized by a progressive, non-fluctuating ophthalmoplegia.2, 3 Furthermore, the ophthalmoplegia in mitochondrial dysfunction is usually fairly conjugate. That is, it has approximately equal amounts of misalignment in different fields of gaze. Additionally, isolated weakness of the bilateral medial rectus muscles has not to our knowledge been described in patients with mitochondrial disorders affecting the extraocular muscles. The motility disorder as described in Fig. 11 could represent bilateral internuclear ophthalmoplegias (INO). INO is associated with demyelinating or ischemic disease of the brainstem nuclei,4 as well as with metabolic toxicities and disorders including Wernicke encephalopathy5 and hepatic encephalopathy.6 INO is characterized by impaired adduction of one or both eyes with divergent misalignment, often with adduction lag that may fluctuate with patching.7 We question whether any other evidence of Wernicke encephalopathy was seen in the patient population. The differential of fluctuating extraocular dysmotility also includes ocular myasthenia, a motility disorder characterized by fatigable dysmotility due to a pathologic antibody against the post-synaptic neuromuscular junction. Myasthenia may often be associated with other autoimmune diseases, rarely with autoimmune hepatitis.8 In summary, we question the authors' association of NASH with mitochondrial dysfunction based on their description of a motility disorder that is, if it is accurately described, not characteristic of the mitochondrial myopathies.
- 3Mitochondrial disease and the eye. Ophthalmol Clin North Am 1992; 5: 405–424..
Jerome Schartman*, Joel Weinstein*, * Ophthalmology, Penn State College of Medicine, Hershey, PA.