Graefe’s Arch Clin Exp Ophthalmol(2006) 244: 1060–1061

DOI 10.1007/s00417-005-0223-0

LETTER TO THE EDITOR

Ji Soo KimJeong-Min Hwang

Received: 16 September 2005Revised: 3 November 2005Accepted: 23 November 2005Published online: 13 January 2006# Springer-Verlag 2006

Topical diclofenac for the treatment of eyeachein Miller–Fisher syndrome

Dear Editor,Miller–Fisher syndrome (MFS) is anuncommon disease characterized byophthalmoplegia, ataxia, and areflexia[2], accounting for 5% of cases ofGuillain–Barre syndrome (GBS) inmost series [7]. Pain can be a prominentfeature of GBS. Low back pain, deepmuscular soreness, and burning or lan-cinating extremity pain have all beenreported [6]. A report was also issued onthe successful treatment of severe con-stant aching and burning in feet withtopical capsaicin 0.075% [5]. However,no report has been issued on the treat-ment of eyeache in MFS.

A 35-year-old man was referred fordiplopia. Two weeks after a commoncold he developed double vision, and theday before diplopia onset he developedataxia. He had no significant medicalhistory and was taking no medicationsother than non-prescription medicationsfor the common cold. The patient hadnot experienced recent diarrhea, and noone at his home was ill. He denieddysphagia, dysarthria, incontinence,paresthesias, vertigo, neck stiffness,fever, tick bite, or head trauma. He had amild eyeache on eye movement. Hisvisual acuities were 20/20 in the righteye and 20/25 in the left eye. His pupilswere isocoric and reactive to light, andhis fundoscopic examination was nor-mal. He had a mild bilateral ptosis andupward and horizontal gaze limitationsin both eyes. He showed right esotropiaand hypertropia in the primary position,which increased with upgaze and de-creased with downgaze. Cranial nervesand cerebellar functionwere normal.Hisstrength was normal throughout, butdeep tendon reflexes at the biceps,patella, and ankle were hypoactive.Muscle tone was normal, and there wasno evidence of atrophy or fasciculations.

Sensations to light touch and to pinprickwere intact, and proprioception wasnormal.

On admission, nerve conductionstudies did not reveal any significantperipheral neuropathy or demyelina-tion, and the patient’s cerebrospinalfluid examination and brain MRIfindings were normal. He was admi-nistered intravenous immunoglobulinG (2 g/kg). Two days after the immu-noglobulin therapy, the diplopia andptosis improved, but the eyeache,especially during eye movement, be-came aggravated. Diclofenac 0.1%(Voltaren Ophtha, Ciba Vision Oph-thalmic, Duluth, GA) was appliedtopically every 6 h to both eyes. Thepatient noticed a definite pain reliefafter diclofenac instillation for 4–5days. One week later, topical diclo-fenac was stopped because the painhad decreased markedly.

Little is known about pain in MFS.One report that systematically studiedpain in MFS showed that 6 of 27 MFSpatients (22%) had pain, and of theseonly 3 complained of orbital pain [3].The use of oral nonsteroidal anti-in-flammatory drugs failed to relieve thepain satisfactorily in most of the sixpatients [3]. However, topical diclofenac0.1% effectively controlled eyeache inour MFS patient. Diclofenac modulatesthe cyclo-oxygenase pathway directlyand the lipoxygenase pathway indi-rectly, thus reducing the production ofprostaglandins and leukotrienes, whichare the main mediators of inflammatoryresponses [4]. It is also effective atdecreasing postsurgical pain andinflammation [1].

In conclusion, topical diclofenac ap-pears to be effective at relievingMFS-associated eyeache.

J. S. KimDepartment of Neurology,Seoul National University Collegeof Medicine, Seoul National UniversityBundang Hospital,Seongnam, South Korea

J.-M. Hwang (*)Department of Ophthalmology,Seoul National University Collegeof Medicine, Seoul National UniversityBundang Hospital,300 Gumi-dong, Bundang-gu,Seongnam, Gyeonggi-do, 463-707,South Koreae-mail: hjm@snu.ac.krTel.: +82-31-7877372Fax: +82-31-7874057

References

1. Apt L, Voo I, Isenberg SJ (1998)A randomized clinical trial of thenonsteroidal eyedrop diclofenac afterstrabismus surgery. Ophthalmology105:1448–1452

2. Fisher M (1956) An unusual variant ofacute idiopathic polyneuritis (syndromeof ophthalmoplegia, ataxia, and are-flexia). N Engl J Med 255:57–65

3. Koga M, Yuki N, Hirata K (2000) Painin Miller Fisher syndrome. J Neurol247:720–721

4. Ku EC, Lee W, Kothari HV, ScholerDW (1986) Effect of diclofenac sodiumon the arachidonic acid cascade. AmJ Med 28:18–23

5. Morgenlander JC, Hurwitz BJ, MassayEW (1990) Capsaicin for the treatmentof pain in Guillain-Barre syndrome.Ann Neurol 28:199

6. Moulin DE, Hagen N, Feasby TE,Amireh R, Hahn A (1997) Pain inGuillain-Barre syndrome. Neurology48:328–331

7. Ropper AH (1992) The Guillain-Barrésyndrome. N Engl J Med 326:1130–1136

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