Teaching Video NeuroImage: Uncommon Neuro-ophthalmic Finding in a Patient With Miller Fisher Syndrome and Past SARS-CoV-2 Infection

A 21-year-old woman developed diplopia, rhinolalia, and movement imbalance 3 weeks after COVID-19. On neurologic examination, she presented with left mydriasis, mild bilateral lateral rectus palsy, and horizontal gaze-evoked eyelid nystagmus (Video 1). The patient’s generalized hyporeflexia and ataxic gait were consistent with symptoms of Miller Fisher syndrome (MFS). A test for GQ1b antibodies returned positive. Despite immunoglobulin therapy, the patient developed respiratory failure requiring mechanical ventilation. The symptoms improved over the succeeding days. MFS has been associated with COVID-19, but this is the first case with positive GQ1b antibodies.1 Eyelid nystagmus is an intermittent upward jerking of eyelids associated with posterior fossa lesions that can also be present in MFS.2

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