A previously healthy 18 year old male presented to ophthalmology with acute onset binocular diplopia after an upper respiratory infection resolving the week prior. The patient was found to have a left cranial nerve (CN) 6 palsy with MRI brain only notable for extensive maxillary sinus disease. Three days later, the patient developed a left CN 4 palsy, left ptosis and right CN 6 palsy. Ice-pack test on the left appeared positive, but otherwise neurologic exam was unremarkable at the time. Evaluation for myasthenia gravis and cavernous sinus involvement was negative. Two days later, he had diminished deep tendon reflexes with only trace bilateral brachioradialis and left biceps, and the following day, he was completely areflexic. His condition remained stable during his hospitalization. Anti-GQ1b antibody was positive confirming Miller Fisher Syndrome.

At 2 month follow up, the patient showed significant improvement in extra-ocular movements and return of Achilles reflexes bilaterally, but had persistent esotropia causing diplopia.