Bilateral internuclear ophthalmoplegia in multiple sclerosis of very late onset

Context: Multiple sclerosis (MS) is the most common demyelinating disease of the central nervous system. The average age of onset is in the range of 28 to 31 years, but it can occur from the first year of life or after the seventh decade. If diagnosed over 60 years of age, it is called very late onset, with low prevalence. Bilateral internuclear ophthalmoplegia is a rare syndrome characterized by bilateral restriction of the adduction of the eyes in the conjugated horizontal gaze, which is generally secondary to demyelinating and vascular diseases. Case report: A 64-year-old man, brown, with a history of alcoholism, gout, hypothyroidism, arterial hypertension and generalized osteoarthritis with a right hip prosthesis with difficulty walking, presented a five-day subacute bilateral visual turbidity and binocular horizontal diplopia. On physical examination, he presented bilateral internuclear ophthalmoplegia, with a reduction in bilateral visual acuity worse on the right, in addition to lower limb pain pseudoparesis, with bilateral Babinski sign. Investigation with visual evoked potential demonstrated bilateral demyelinating optic neuropathy on the right, cerebrospinal fluid with more than two oligoclonal bands present, neuroaxis magnetic resonance imaging showing a change in the signal of the right optic nerve and multiple demyelinating lesions, fulfilling the criteria for dissemination in space and time. Therapy with Methylprednisolone 1g / day for 5 days was performed, with improvement of the condition, maintaining only visual sequelae with decreased visual acuity, and disease-modifying therapy was also started with stabilization of the condition. Conclusions: Despite being more rare, very late-onset MS should be considered as a diagnosis, even with singular presentations as in the case reported.