Abstract
A 54-year-old man presented with coma and left mydriasis due to bilateral thalamic and left paramedian midbrain infarcts. Workup revealed paradoxical embolism from an intrapulmonary shunt. As the patient's mental status improved, complex eye movement abnormalities emerged, including vertical ophthalmoplegia, bilateral ptosis, and right pseudo-abducens palsy. This case highlights the complex and often-overlooked ocular motor neural circuitry in the thalamo-mesencephalic junction.