Reply to comments on the case report of “Fleeting diplopia and wobbly feet: Miller-Fisher syndrome – Presenting as bilateral abducent nerve palsy”

Dear Editor, We sincerely thank Chaurasiya and Suraj Kumar et al. for taking their valuable time to review our article, ’Fleeting diplopia and wobbly feet: Miller-Fischer syndrome presenting as bilateral abducent nerve palsy.’ Your valuable observations and insightful comments are appreciated. Regarding the limitations encountered during the evaluation and treatment, we work hand in hand with neurologists when dealing with neurological/neuro-ophthalmic conditions. We do not view this as a limitation; rather, we consider it our responsibility to refer the patient to the neurologist promptly for their expert opinion. We use their inputs along with our clinical diagnosis to define the future course of management. The same approach was followed here as well. Regarding the follow-up, we agree that we did not mention a long follow-up in the case report. However, we have follow-up data for 6 months post intravenous immunoglobulin (IVIG) therapy. The patient has recovered with full eye movements and has no ataxia. The patient however continues to have a small esotropia persisting in primary gaze with diplopia, for which he was prescribed Fresnel prism with which he is managing well. In our article, we aimed to sensitize the general ophthalmologist to the salient features of a rare neurological syndrome as well as to highlight how it could present in a regular outpatient department. We did not dive into the depth of various manifestations and presentations in detail due to the constraints of case reporting. The core clinical presentations to an ophthalmologist are diplopia with symmetrical ophthalmoparesis and lateral rectus (100%) being most commonly involved, followed by superior rectus (60%), inferior (52%), and medial (48%) rectus muscle.[1] Most of the patients present 10–15 days following an antecedent event. Eye manifestations vary from complete ophthalmoplegia, external ophthalmoplegia, internuclear ophthalmoplegia, acute ptosis, and so on.[1,2] Involvement of other cranial nerves (other than 6,3,4) and paresis of the extremities have been reported.[1] Detailed attention to the subtle neurological findings in any patient presenting with diplopia or ophthalmoparesis, along with features of ataxia, with proper neurological evaluations can avoid delay in diagnosis, facilitate early management, and hasten recovery. We respect the points of view expressed by our esteemed colleagues and hope this case gives more insights when a similar presentation comes in the future. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.