Sustained downgaze mostly occurs in association with lesions affecting the dorsal midbrain. We report
sustained downgaze in a patient with hepatic encephalopathy. The sustained downgaze existed for
seven more days after she regained her consciousness. The persistent downgaze even after regaining
full consciousness indicates localized pretectal dysfunction rather than diffuse encephalopathy as the
mechanism of sustained downgaze in our patient. The ocular motor dysfunction in hepatic encephalopathy
may be due to localized dysfunction of the brainstem
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