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Paper text:
a thirty - five - year - old male patient presented to our department complaining of diplopia of 6 days duration .  
ten days previously , he had suffered a chest infection for which he had a course of antibiotics and had made a good recovery . on examination ,
colour vision tested with ishihara plates was normal , and visual field testing by confrontation was also normal .
ocular motility testing revealed signs suggesting bilateral fourth nerve palsy and bilateral sixth nerve palsy .
all his reflexes were absent and he had truncal unsteadiness when carrying out heel - to - toe walking .
a formal orthoptic assessment was carried out which verified the presence of bilateral fourth and sixth nerve palsy ( figures 4 , 5 , 6 , 7 , 8 , 9 , and 10 ) . pharmacological testing with 0,125%
subsequently , the patient had a brain mri scan that did not reveal any abnormalities . on the basis of the clinical findings a diagnosis of miller
serum samples were tested for anti - gq1b ganglioside antibodies and an elevated igg titer was reported .
it was first described in 1956 as a triad of ophthalmoplegia , ataxia , and areflexia .
anti - gq1b ganglioside antibodies have been shown to be a serum marker for mfs .
they can be found in 85% of cases and have been proposed as one of the diagnostic criteria for mfs .
an mri of the brain is not necessary to make the diagnosis which can be made solely on clinical grounds having excluded other pathology .
usually , abnormal high intensity lesions of the brainstem , thalamus , cerebellum , and cerebrum are seen on mri in patients with bickerstaff 's brainstem encephalitis with ophthalmoplegia , ataxia and hypereflexia .
the differential diagnosis also includes botulism , cerebrovascular accident , myasthenia gravis , and wernicke 's encephalopathy with the latter being the one closer mimicking mfs , usually presenting with mental changes , ataxia , and extraocular muscle paralysis with nystagmus in a person with nutritional deficiency precipitated by infection , gastrointestinal disorder or trauma .
the full triad of mfs is not always present   and there might be an overlap with gbs .
mydriasis which exhibits denervation hypersensitivity with or without light - near dissociation is also not always present .
the natural recovery of the condition is very good in the majority of cases with or without treatment .
there are no randomised controlled trials of immunomodulatory therapy in mfs on which to base practice yet .
intravenous immunoglobulin has been shown to slightly hasten the periods between ophthalmoplegia and ataxia onset and the start of the alleviation of these symptoms .
ophthalmologists should maintain a high level of suspicion of mfs as they may be the first doctors to encounter this condition .
careful history taking and the bilaterality of the condition are keys to the diagnosis even though unilateral cases have been reported .
after other pathology has been excluded , a prompt referral to a neurologist is mandatory as the condition may progress to gbs   with devastating consequences .
miller - fisher syndrome ( mfs ) is a rare condition characterized by the classical triad of ophthalmoplegia , ataxia , and areflexia ( fisher , 1956 ) . 
 it is considered a variant of guillain - barr syndrome ( gbs ) with which it may overlap , or it can occur in more limited forms . 
 we report a case of a thirty - five - year - old male who presented with a six - day history of diplopia , following a recent chest infection . on examination 
 , he was found to have bilateral sixth nerve palsy , bilateral fourth nerve palsy , bilateral areflexical mydriasis , ataxia and total absence of reflexes . after excluding other conditions , 
 a diagnosis of miller - fisher syndrome was made . 
 the patient was administered intravenous immunoglobulin and made an uneventful recovery .