Fleeting diplopia and wobbly feet: Miller-Fisher syndrome-presenting as bilateral abducent nerve palsy

Abstract

A case report of a healthy young male, presented with binocular diplopia of sudden onset with mild bilateral abduction limitation, progressed rapidly to near total ophthalmoplegia. Rest of the ophthalmic examination, blood pressure, and magnetic resonance imaging of brain were normal. Basic blood work-up was normal except mildly raised serum triglycerides. He gave a history of mild giddiness and ataxia. Neurological evaluation done showed absent deep tendon reflexes and serum anti-GQ1b antibody was raised. A diagnosis of Miller-Fisher syndrome was made and he was given intravenous immunoglobulin. Post-treatment his ocular motility recovered well, with minimal residual diplopia noted for distance. In individuals with abducent nerve palsy, normal imaging, and no systemic risk factors, a careful history asking for subtle neurological symptoms and a complete central nervous system examination is warranted to rule out conditions like Miller-Fisher syndrome which may not be a familiar entity to many ophthalmologists.