Neuro-ophthalmic manifestations of the syndrome of ophthalmoplegia, ataxia and areflexia: a review

Sensitivity of Magnetic Resonance Imaging of the Medial Longitudinal Fasciculus in Internuclear Ophthalmoplegia

BACKGROUND

Internuclear ophthalmoplegia (INO) is a result of insult to the medial longitudinal fasciculus (MLF). Clinicoradiological correlation in patients with INO has been reported to be poor; however, prior studies have used low resolution MRI imaging techniques and included patients with subclinical INO. We aimed to determine the sensitivity of modern MRI interpreted by a specialist neuroradiologist to detect clinically evident INO.

METHODS

A retrospective chart review of patients in 2 tertiary University-affiliated neuro-ophthalmology practices with the diagnosis of INO. MRI scans of all patients were reviewed and interpreted by a fellowship-trained neuroradiologist for the presence of lesion in MLF and concordance with the original imaging report.

RESULTS

Forty-five patients were included in the study: 33 with demyelinating disease, 11 with stroke, and 1 with intracranial mass. A visible MLF lesion was present in 25/33 demyelinating cases and 7/11 ischemic cases. Lesions in 2 cases in each group were identified only after review by a fellowship-trained neuroradiologist. In demyelinating INO, patients with a visible MLF lesion were more likely to show other brainstem (72%) and supratentorial (51%) white matter lesions.

CONCLUSIONS

In 25% of patients with demyelinating INO and 33% of patients with ischemic INO, no visible lesion was identified on current high-quality MRI imaging. Review of imaging by a neuroradiologist increased the possibility of lesion been identified.

Eyes wide open—an atypical presentation of Miller Fisher syndrome (MFS): case report

Background

Parinaud’s syndrome, also known as dorsal midbrain syndrome, is characterized by a combination of signs, including upgaze palsy, convergence–retraction nystagmus, eyelid retraction and pupillary dissociation. It is caused by pretectal or tegmental lesions of upper brainstem. Miller Fisher syndrome, characterized by the triad of ataxia, areflexia and ophthalmoplegia, has rarely been reported to present as Parinaud’s syndrome in adults. To our knowledge, this clinical manifestation has not been previously described in children.

Case presentation

A previously healthy 13-year-old girl presented with blurred vision and diplopia, 10 days after a viral infection. Initial examination revealed incomplete Parinaud’s syndrome, while rest of neurological examination was normal. Brain imaging (MRI, MRA) did not reveal any abnormal findings and CSF findings were also normal. During the first days after admission she gradually deteriorated, showing complete external ophthalmoplegia, unsteady gait, and absent deep tendon reflexes of lower limbs with normal muscle power. With the clinical suspicion of Miller Fisher syndrome IVIG was administered, leading to subsequent resolution of her symptoms. AntiGQ1b and antiGD1b antibodies came back positive confirming diagnosis. On 1 month follow-up, neurological examination revealed diplopia in left gaze, and a second dose of IVIG was administered with good response. She remains asymptomatic 1 year from disease onset.

Conclusions

Miller Fisher syndrome can rarely present as Parinaud’s syndrome in adults. Herein we described the first pediatric patient with similar clinical presentation. As the typical semiology of ataxia and areflexia may not be present initially, high index of suspicion is required to recognise and treat those patients promptly. Serological detection of anti-ganglioside antibodies, such as anti-GQ1b and anti-GD1b, may help confirm diagnosis.

Late Presentation of Ataxia, Areflexia, and Electrophysiological Abnormalities as Part of Miller Fisher Syndrome: Case Report

Miller Fisher syndrome (MFS) is characterised by the triad of ophthalmoplegia, ataxia, and areflexia. A case with external ophthalmoplegia and absence of ataxia and areflexia until the end of second week is presented. Electrophysiological findings became apparent after the third week and showed reduced amplitudes of sensory nerve action potentials and prolonged latencies of F with no evidence of conduction blocks. There was no response to intravenous immunoglobulin, but there was response to corticosteroids. This case may represent an atypical MFS with late presenting electrophysiological abnormalities. Corticosteroids can be a therapeutic option when intravenous immunoglobulin fails to control clinical symptoms.

Parkinson's disease: from genetics to clinical practice

Breakthroughs in genetics over the last decade have radically advanced our understanding of the etiological basis of Parkinson's disease (PD). Although much research remains to be done, the main genetic causes of this neurodegenerative disorder are now partially unraveled, allowing us to feel more confident that our knowledge about the genetic architecture of PD will continue to increase exponentially. How and when these discoveries will be introduced into general clinical practice, however, remains uncertain. In this review, we provide a general summary of the progress in the genetics of PD and discuss how this knowledge will contribute to the diagnosis and clinical management of patients with, or at risk of this disorder.

Pupillary Involvement in Miller Fisher Syndrome

Miller Fisher Syndrome is characterised by the classical triad of ophthalmoplegia, ataxia, and areflexia. Ophthalmoparesis without ataxia, without areflexia, or with neither have been attributed as atypical forms of MFS. We report two patients with MFS who had tonic pupils and raised anti-GQ1b antibody titres. Bilateral dilated pupils (either tonic or fixed) can be a manifestation of MFS and anti-GQ1b immunoglobulin G (IgG) antibodies are useful to confirm the diagnosis in unexplained cases. The site of involvement is thought to be the ciliary ganglion or short ciliary nerves.

Fisher syndrome: clinical features, immunopathogenesis and management

Since Miller Fisher's first report in 1956, evidence has accumulated about clinical and laboratory features, immunopathogenesis and treatment of Fisher syndrome (FS). Our literature review revealed the nature of FS. It has relatively uniform clinical and laboratory features. Ophthalmoplegia, ataxia and areflexia are essential prerequisites for an FS diagnosis, but there are several clinical variants with isolated ophthalmoplegia or ataxia. The discovery of serum anti-GQ1b antibody in FS has led to breakthroughs in FS research. The antibody is thought to be a key factor in the pathogenesis of FS, the understanding of which has progressed owing to the discovery of molecular mimicry between GQ1b and the lipo-oligosaccharides of Campylobacter jejuni and Haemophilus influenzae. The lesions responsible for the clinical symptoms have been debated but are close to clarification. Hence, the pathogenesis of FS has been made much clearer, although there are still some unanswered questions.

Cd2+, Mn2+, Ni2+ and Se2+ toxicity to Saccharomyces cerevisiae lacking YPK9p the orthologue of human ATP13A2

The Saccharomyces cerevisiae gene YPK9 encodes a putative integral membrane protein which is 58% similar and 38% identical in amino acid sequence to the human lysosomal P(5B) ATPase ATP13A2. Mutations in ATP13A2 have been found in patients with Kufor-Rakeb syndrome, a form of juvenile Parkinsonism. We report that Ypk9p localizes to the yeast vacuole and that deletion of YPK9 confers sensitivity for growth for cadmium, manganese, nickel or selenium. These results suggest that Ypk9p may play a role in sequestration of divalent heavy metal ions. Further studies on the function of Ypk9p/ATP13A2 may help to define the molecular basis of Kufor-Rakeb syndrome and provide a potential link to environmental factors such as heavy metals contributing to some forms of Parkinsonism.

Defective responses to DNA single- and double-strand breaks in spinocerebellar ataxia

Failure to maintain the integrity of DNA/chromatin can result in genome instability and an increased risk of cancer. The description of a number of human genetic disorders characterised not only by cancer predisposition but by a broader phenotype including neurodegeneration suggests that maintaining genome stability is also important for preserving post-mitotic neurons. The identification of genes associated with other neurodegenerative disorders provides further evidence for the importance of DNA damage response and DNA repair genes in protecting against neurodegeneration. This theme is further developed in this review.

Clinical and immunological spectrum of the Miller Fisher syndrome

The Miller Fisher syndrome (MFS), characterized by ataxia, areflexia, and ophthalmoplegia, was first recognized as a distinct clinical entity in 1956. MFS is mostly an acute, self-limiting condition, but there is anecdotal evidence of benefit with immunotherapy. Pathological data remain scarce. MFS can be associated with infectious, autoimmune, and neoplastic disorders. Radiological findings have suggested both central and peripheral involvement. The anti-GQ1b IgG antibody titer is most commonly elevated in MFS, but may also be increased in Guillain-Barré syndrome (GBS) and Bickerstaff's brainstem encephalitis (BBE). Molecular mimicry, particularly in relation to antecedent Campylobacter jejuni and Hemophilus influenzae infections, is likely the predominant pathogenic mechanism, but the roles of other biological factors remain to be established. Recent studies have demonstrated the presence of neuromuscular transmission defects in association with anti-GQ1b IgG antibody, both in vitro and in vivo. Collective findings from clinical, radiological, immunological, and electrophysiological techniques have helped to define MFS, GBS, and BBE as major disorders within the proposed spectrum of anti-GQ1b IgG antibody syndrome.

Mydriasis with Light-Near Dissociation in Fisher's Syndrome

BACKGROUND

Approximately 50% of patients with Fisher's syndrome show involvement of the pupillomotor fibers and present with mydriasis and light-near dissociation. However, it is uncertain whether this phenomenon is induced by an aberrant reinnervation mechanism as in tonic pupil, or is based on other mechanisms such as those associated with tectal pupils.

CASES

We evaluated the clinical course and the pupillary responses in four of 27 patients with Fisher's syndrome who presented with bilateral mydriasis.

OBSERVATIONS

The pupils of both eyes of the four patients were involved at the early stage of Fisher's syndrome. The pupils in patients 1 and 2 showed mydriasis with apparent light-near dissociation lasting for a significant period and had denervation supersensitivity to cholinergic agents. On the other hand, the pupils of patients 3 and 4 were dilated and fixed to both light and near stimuli.

CONCLUSIONS

Our observations indicate that the denervated iris sphincter muscles, which are supersensitive to the cholinergic transmitter, may play an important role in the expression of light-near dissociation in Fisher's syndrome.

[Miller Fisher syndrome: case report and review with discussion of differential diagnosis and nosology]

We report a 52-year-old patient with Miller Fisher syndrome and discuss Wernicke's encephalopathy as one important differential diagnosis. This article focuses on diagnostic criteria and possible nosological relations between Miller Fisher syndrome, Guillain-Barré syndrome with ophthalmoplegia, Bickerstaff's brainstem encephalitis, and acute ophthalmoparesis without ataxia.

The double vision decision

A 50-year-old man experienced the acute onset of ophthalmoplegia, ataxia, and hyporeflexia. Evaluation led to the diagnosis of Miller Fisher syndrome (MFS). Appropriate evaluation and management of MFS is discussed.

Anti-GQ1b IgG antibody syndrome: clinical and immunological range

OBJECTIVES

To clarify the nosological relation among Miller Fisher syndrome (MFS), Guillain-Barré syndrome (GBS) with ophthalmoplegia, Bickerstaff's brain stem encephalitis (BBE), and acute ophthalmoparesis without ataxia. Serum samples from patients with each condition often have anti-GQ1b IgG antibody.

METHODS

Information on antecedent illness, initial symptoms, neurological signs during the illness, and CSF findings were reviewed in 194 patients with anti-GQ1b IgG. It was determined whether overlapping MFS and GBS (MFS/GBS), as well as overlapping BBE and GBS (BBE/GBS), is explained by the combined action of anti-GQ1b IgG and anti-GM1 or anti-GD1a IgG, serological markers of GBS.

RESULTS

Based on the diagnostic criteria, all the patients with acute ophthalmoparesis, MFS, MFS/GBS, BBE/GBS, and BBE had external ophthalmoplegia; all the patients with MFS, MFS/GBS, or GBS had hyporeflexia or areflexia; and all those with MFS and BBE showed ataxia. Tendon reflexes were decreased or absent in 91% of those with BBE/GBS, 67% of those with BBE, and 53% of those with acute ophthalmoparesis. Ataxia was present in 68% of the patients with MFS/GBS and 45% of those with BBE/GBS. Antecedent illness caused by upper respiratory tract infection had occurred in 60% to 80% of these patients, and CSF albuminocytological dissociation in 25% to 75%. Anti-GM1 or anti-GD1a IgG was present in 50% of those with GBS, 35% of those with MFS/GBS, 27% of those with BBE/GBS, 16% of those with MFS, and 8% of those with BBE.

CONCLUSIONS

These findings together with the common autoantibody (anti-GQ1b IgG) suggest that a common autoimmune mechanism functions in the pathogenesis of these illnesses. In a larger study, it was confirmed clinically that MFS, GBS, BBE, and acute ophthalmoparesis are closely related, forming a continuous range. This is supported by the immunological findings. The term "anti-GQ1b IgG antibody syndrome" is not intended to be used as a clinical diagnosis, but recognition of this syndrome is useful for understanding the aetiological relation among the various illnesses and for introducing the established treatments of GBS for use with other conditions.

Miller Fisher syndrome: unique involvement of ophthalmic division of trigeminal nerve

The clinical, electrophysiological, and radiological features of a patient with a typical Miller Fisher Syndrome are reported. The patient has shown a unique affection of the ophthalmic division of the trigeminal nerve. The significance of serial electrophysiological testing particularly blink reflex study is discussed.

Miller Fisher-Guillain-Barré overlap syndrome with enhancing lesions in the spinocerebellar tracts

The site of lesions in Miller Fisher syndrome, especially those causing ataxia, has been controversial. A 50 year old man with features of Miller Fisher syndrome in whom MRI showed enhancing lesions in the spinocerebellar tracts at the level of the lower medulla is reported. Peripheral involvement of cranial nerves was also indicated by an abnormal blink reflex and by clinical manifestations: complete external ophthalmoplegia, bilateral peripheral facial weakness, convergence disturbance, absence of Bell's phenomenon, oculocephalic, and oculovestibular reflex. Abnormal lesions on MRI disappeared and the blink reflex became normal with clinical improvement. The case is regarded as Miller Fisher-Guillain-Barré overlap syndrome, a postinfectious allergic reaction involving both peripheral nerves in the cranium and neuraxis in the spinocerebellar tract. The lesions in the spinocerebellar tracts are responsible for cerebellar ataxia in this syndrome.