Amaurotic and ophthalmoplegic presentation of Balint syndrome.

A 54-year-old woman developed acute hypertensive encephalopathy associated with acetaminophen-induced liver failure. Examination showed blindness with absence of horizontal and vertical volitional and reflex saccades (video on the Neurology® Web site at Neurology.org, first segment). MRI showed biparieto-occipital signal abnormalities consistent with the posterior reversible encephalopathy syndrome (PRES) (figure). Within 24 hours, visual acuity and eye movements improved, but the patient developed ocular apraxia (increased saccadic latency), optic ataxia (impaired visual navigation), and simultanagnosia (inability to recognize more than a single object): the Balint syndrome (video, second segment). This illustrates that a severe expression of oculomotor apraxia can mimic complete ophthalmoplegia and that Balint syndrome may occur at the onset and during recovery from PRES.