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ralysis of conjugate gaze Usually there is some combination of these abnormalities (see Chap 14) Next to nystagmus, the most frequent ocular abnormality is lateral rectus weakness, which is bilateral but not necessarily symmetrical and is accompanied by diplopia and internal strabismus With complete paralysis of the lateral rectus muscles, nystagmus is initially absent in the abducting eyes, but it becomes evident as the weakness improves The palsy of conjugate gaze varies from merely a nystagmus on extreme gaze to a complete loss of ocular movement in that direction This applies to both horizontal and vertical movements, abnormalities of the former being somewhat more frequent Paralysis of downward gaze is an unusual manifestation, but a pattern that simulates internuclear ophthalmoplegia has been seen.

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In advanced stages of the disease there may be a complete loss of ocular movements, and the pupils, which are otherwise usually spared, may become miotic and nonreacting Ptosis, small retinal hemorrhages, involvement of the near-far focusing mechanism, and evidence of optic neuropathy occur occasionally, but we and our colleagues have never observed papilledema in this disease Although the aforementioned ocular signs are highly characteristic of Wernicke disease, disappearance of nystagmus and an improvement in ophthalmoparesis within hours or a day or two of the administration of thiamine con rms the diagnosis Ataxia Essentially the ataxia is one of stance and gait; in the acute stage of the disease, it may be so severe that the patient cannot stand or walk without support Lesser degrees are characterized by a wide-based stance and a slow, uncertain, short-stepped gait; the mildest degrees are apparent only in tandem walking.

27,28 Recent advances in the delivery of the RF energy to the vein will hopefully increase the ef cacy of this procedure Lasers with hemoglobin-predominant absorption (810 nm, 940 nm, 980 nm) Endovenous laser treatment with these wavelengths are similar to RF in that both devices produce endothelial and vein wall shrinkage by nonspeci c heating of the vessel The target for lasers with wavelengths of 810, 940, and 980 nm is the intravascular red blood cell The success of these lasers is highly dependent on correct placement of tumescent local anesthesia to have a thin layer of blood surrounding the laser ber while having enough anesthesia to protect the surrounding nerves and muscles from injury Direct thermal effects on the vein wall without the presence of blood probably do not occur Consistent results may be hard to duplicate given that these lasers are dependent on so.

In contrast to the gross disorder of locomotion is a relative infrequency of limb ataxia and intention tremor; when present, they are more likely to be elicited by heel-to-knee than by nger-to-nose testing Dysarthric, scanning speech is present only rarely Disturbances of Consciousness and Mentation These are present in some form in all but 10 percent of patients Several related types of deranged mentation and consciousness can be recognized By far the most common disturbance is a global confusional state The patient is apathetic, inattentive, and indifferent to his surroundings Spontaneous speech is minimal and many questions are left unanswered, or the patient may suspend conversation and drift off to sleep, although he can be aroused without dif culty Such questions as are answered by the patient betray disorientation in time and place, misidenti cation of those around him, and an inability to grasp the immediate situation.

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