Treatment of GBS has included the use of corticosteroids, plasmaphere-

sis, immunoglobulins, physical therapy, and occupational therapy.3 Until

now, the literature has lacked description of orthoptic intervention for the

ocular motor sequelae of GBS. We report the successful orthoptic manage-

ment of a patient with GBS who had severe residual divergence insuffi-

ciency and esotropia after complete bilateral ophthalmoplegia.

History A 50-year-old ophthalmologist (author KZ) became vertiginous

early one morning while conducting clinical rounds. Within a few hours, he

developed progressive bilateral dysfunction of all cranial nerves with the

exception of I, II, and X. He was unable to chew, swallow or speak. Diplo-

pia evolved as a result of complete external ophthalmoplegia. There was an

efferent pupillary defect in both eyes. Prior to the onset of diplopia, there

was no known oculomotor anomaly, and distance and near phorias were

negligible. Normal (40 sec arc) stereopsis was present. An MRI of the brain

was negative. Neurologic evaluation revealed generalized weakness and are-

flexia. Cerebrospinal fluid and electrophysiological studies were also consis-

tent with a diagnosis of GBS. The patient required hospitalization for four

months and extended physical therapy for two years.

An orthoptic evaluation was performed two months after hospital dis-

charge. A 40 pd esotropia at distance and a 35 pd esotropia at near, combined

with 6 pd of right hypertropia, were measured. He had been advised to patch

one eye to eliminate diplopia. This proved to be unacceptable, since he was

unable to work or navigate with the patch. Eventually a 40 pd base out Fresnel

prism, split unevenly between the two eyes (30 BO=6BD OD and 10 BO

OS), was prescribed. This eliminated the diplopia; however, the optics in-

duced both chromatic aberration and reduced visual acuity. Thus, the Fresnel

prisms were too disturbing to allow him to resume a full, active professional

life.

Diagnostic examination and therapeutic regimen He was

examined by one of us (JC) three months after his initial orthoptic evalua-

tion. After removing the prismatic glasses, the cover test revealed a 40 pd al-

ternating esotropia at distance and a 35’ pd alternating esotropia at near. There

was an associated 4 pd of right hypertropia with degrees of right

excyclotorsion at both test distances. Extraocular movements were full.

There was no observable nystagmus. Pupillary responses were brisk in each

eye without evidence of a Marcus-Gunn pupil. There was incomplete clo-

sure of both the right and left eyelids; however, slit-lamp examination was

negative for exposure keratitis. With a modified Hess screen, the

esodeviation was found to be concomitant, except for a small right hyper-

deviation which increased on right head tilt and adduction. This was consis-

tent with the diagnosis of a mild right superior oblique paresis with

overaction of the ipsilateral inferior oblique. Dilated fundus examination

was unremarkable.

Distance fusional divergence amplitudes were x/-30/-36 (blur. with fu-

sion/disruption of fusion/recovery of fusion), and near fusional divergence

amplitudes were x/-25/-36; blur was not reported, and the negative values

indicated grossly abnormal binocular fusion. With a corrective prism in

place, he was able to detect 40 sec arc of horizontal retinal disparity (Titmus

stereo test). The patient was given the following prescription: OD — 1.50

250

J.Cooperetal.