Snapshot A 5-year-old boy is brought to his pediatriatrician for diplopia. His mother noticed he is unable to look up at her. His symptoms have been associated with episodes of nausea and he has complained of a headache. Physical exam is notable for an upward gaze palsy and a pupillary light-near dissociation. An MRI of the brain demonstrates a pinealoma. Introduction Definition neuro/optical symptoms caused by pressure on the rostral or upper midbrain (pretectal area) results in a supranuclear vertical gaze palsy Etiology Pinealoma Stroke Hydrocephalus Presentation Symptoms diplopia upper eyelid retraction Physical exam upward gaze palsy pupillary light-near dissociation convergence-retraction nystagmus Imaging MRI indication used to identify the what's compressing the pretectal area Treatment Treat underlying cause if present Surgical correction inferior rectus recession superior rectus resection superior transposition of medial and lateral rectus muscles Visual training and tracking exercises