INCOMPLETE MILLER-FISHER SYNDROME AFTER LASIK REFRACTIVE EYE SURGERY AND COVID-19 VACCINATION?

To present a case report of a patient diagnosed with Miller-Fisher Syndrome presented after LASIK refractive eye surgery and the second dose of the BNT162b2 mRNA COVID-19 vaccine.

Optical Express Eye Clinic and University Eye Department of the University Hospital Sveti Duh Zagreb

A 38-year-old previously healthy male patient presented with binocular diplopia two- weeks after the second dose of the BNT162b2 mRNA COVID-19 vaccine and three weeks after laser eye surgery due to myopia. After a complete ophthalmological examination, the patient was referred to a neurological examination which included a brain MRI, lumbar puncture, VEP, ENG, EMG, and serology for autoimmune and infectious disease testing.

During the ophthalmological examination, a bilateral abductor paresis, a discrete vertical gaze palsy, discrete ptosis of both eyes, and pupillary mydriasis were found due to external ophthalmoplegia in oculomotor nerve palsy. The patient complained of diarrhea and fever 3 days after vaccination. Neurological examination showed no ataxia, areflexia, speech, or moving disorders. Macular OCT was unremarkable. The brain MRI showed microangiopathic changes in the cerebral hemispheres. There was no evidence of a visual conduction disorder in VEP testing but increased levels of anti-GQ1b ganglioside antibody in the serum and albuminocytologic dissociation in the cerebrospinal fluid were detected. ENG and EMG were unremarkable. Serological testing showed no proof of infection disease. The treatment with intravenous immunoglobin G was administered and clinical improvement was noted six weeks after the treatment.

Although rare, Miller-Fisher Syndrome with primary ocular manifestation, should be included in the differential diagnosis of patients who present with binocular diplopia following Covid-19 vaccination. Searching the available literature, this is the first described case of Miller-Fisher Syndrome presented after LASIK eye surgery and Covid-19 vaccination. It might be advisable to perform elective eye surgery a few months after the vaccination to avoid misdiagnosis and timely administer treatment.