"Peering at the Tip of the Nose" as a Sign of Thalamic Haemorrhage.

A 76-year-old female presented with sudden onset of left hemiplegia and hemianaesthesia. Examination revealed tonic downward deviation of both eyes and esodeviation of the left eye, with no upgaze beyond midline and mild abduction deficits bilaterally. Bilateral ptosis was seen, reflecting partial levator dehiscence compounded by pseudoptosis due to the depressed position of the eyes. "Peering at the tip of the nose" sign, reflecting acute downward and esodeviation of the eyes, is highly suggestive of thalamic haemorrhage. It is thought to reflect damage to the mesodiencephalic junction, which contains structures important for vertical gaze and vergence. Awareness of this sign may assist clinicians with the correct anatomical localisation of stroke in patients who present with thalamic haemorrhage.