A 29-year-old right handed lady presented with a right one and a half syndrome secondary to ipsilateral pontine haemorrhage. Eight months later she complained of oscillopsia and developed vertical plane predominant ∼2 Hz pendular nystagmus. There was no pharyngeal, facial or diaphragmatic involvement, however, she had a subtle, synchronous palatal tremor and de novo features of inferior olivary nucleus hypertrophic degeneration were seen on repeat MRI. Oculopalatal tremor (OPT) is often misdiagnosed as acquired pendular nystagmus (APN) as palatal tremor may be subtle and asymptomatic. The pathogenesis of OPT is distinct from other causes of APN with implications for optimal treatment.
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