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Managing Diplopia During Recovery From Fisher Syndrome: An Occupational Therapy–Led Oculomotor Rehabilitation Case SeriesManuscript type: Case series: 3 casesKey Clinical MessageDiplopia during recovery from Fisher syndrome can substantially restrict daily activities despite expected spontaneous neurological improvement. This case series illustrates a feasible, equipment-free occupational therapy–led oculomotor rehabilitation approach implemented in a recovery ward to support visual engagement and participation while recovery progressed.AbstractFisher syndrome often presents with acute external ophthalmoplegia, causing diplopia that may persist for weeks to months and interfere with daily activities during recovery. We report three cases of patients admitted to a recovery rehabilitation ward who received occupational therapy–led oculomotor rehabilitation as supportive management during the natural recovery phase. Visual function, strabismus angle, subjective diplopia, and activities of daily living were monitored, and all patients improved without adverse events and returned to independent living or work. This case series illustrates a practical, equipment-free rehabilitation approach to support participation while spontaneous recovery progresses.IntroductionFisher syndrome (FS) is characterized by a triad of acute external ophthalmoplegia, ataxia, and areflexia [1]. External ophthalmoplegia frequently leads to diplopia due to limitations in vertical and horizontal eye movements, substantially affecting daily activities, appearance, and psychological well-being. Although neurological prognosis is generally favorable with spontaneous recovery [2,3], diplopia may persist during the recovery phase and interfere with participation in daily life [4].While several reports have described rehabilitation in FS [5,6], structured approaches focusing on managing diplopia during recovery remain insufficiently detailed. In other neurological conditions, occupational therapy–led oculomotor rehabilitation programs emphasizing pursuit, fixation, saccades, and convergence have been described as feasible and applicable in routine clinical settings without specialized equipment [7-9]. In the present report, we applied previously described oculomotor rehabilitation techniques as supportive management during the recovery phase for three patients with FS admitted to a recovery rehabilitation ward and describe their clinical courses.Case SeriesParticipantsThree patients with FS admitted to a recovery rehabilitation ward between April 2024 and October 2025 were included in this case series. Patients were included if they had no cognitive impairment and provided written informed consent. Case details are summarized in Table 1, and ocular photographs are shown in Figure 1.Case AA 67-year-old woman presented with diplopia, ptosis, and gait disturbance and was diagnosed with FS. She was transferred for rehabilitation on day 19 post-onset. She had mild ataxia (FIM 92). External ophthalmoplegia affected all directions, most severe in right eye adduction, with bilateral ptosis and diplopia in all gaze directions. Her goal was to resume reading music.Case BA 42-year-old woman presented with diplopia and gait disturbance and was transferred on day 19 post-onset. Ataxia had improved (FIM 90). The ophthalmoplegia was characterized by marked right eye abduction impairment. Diplopia was present in the primary gaze and worsened on left gaze. The patient aimed to regain independence in household activities.Case CA 62-year-old man developed sudden diplopia and was transferred on day 18 post-onset. Ataxia had improved (FIM 112). Ophthalmoplegia affected all directions, being most severe in left eye adduction, with diplopia in all gaze directions. He aimed to return to work involving driving.OutcomesOutcomes included strabismus angle and the Visual Function Index (VFI) assessed weekly, along with subjective diplopia [10]. The strabismus angle was calculated via video analysis of maximal pursuit in eight directions using the Hirschberg method [11]. VFI was scored out of 32 points during hospitalization.InterventionTherapy was provided 7 days/week (6–9 sessions/day). Oculomotor rehabilitation was delivered in three daily sessions using a previously described program conducted supine with a target at 30 cm: (i) pursuit in eight directions, (ii) end-range fixation, (iii) random saccades in eight directions, and (iv) convergence with alternating monocular and binocular viewing. Additional exercises (vestibulo-ocular reflex facilitation, forced use of the paretic eye, and self-training) were added as appropriate. All interventions were administered by experienced occupational therapists.Clinical CourseClinical courses and changes in strabismus angle, visual function index, diplopia, and functional outcomes are summarized in Table 2.Case A: Therapy began on day 19. The initial strabismus angle was 48.9, VFI 6/32, with diplopia in all directions. By day 32, primary-gaze diplopia had resolved. By day 54, the strabismus angle had improved to 8.7°, VFI to 31/32, and FIM to 126; the patient was discharged home. Diplopia fully resolved by ~5 months, and the patient returned to work.Case B: Therapy began on day 19 after onset. The initial strabismus angle was 45.3°, the VFI score was 6/32, and diplopia was present in all gaze directions. By day 46, the strabismus angle had improved to 9.3°, the VFI score to 30/32, and the FIM score to 125, at which point the patient was discharged home. She regained independence in household activities by ~3 months.Case C: Therapy began on day 18. The initial strabismus angle was 47.2°, VFI 8/32, with diplopia in all directions. By day 48, the strabismus angle had improved to 9.8°, VFI to 30/32, FIM to 126, and the patient was discharged home. He returned to work by ~3 months.DiscussionImprovements in eye alignment, subjective diplopia, and visual function observed in these cases occurred within the range of recovery periods reported in previous natural history studies of FS [2,3]. Accordingly, this case series does not suggest accelerated neurological recovery attributable to rehabilitation. Rather, its clinical relevance lies in illustrating how structured oculomotor rehabilitation can be safely and feasibly implemented to manage diplopia-related functional difficulties during the recovery phase.Diplopia can substantially limit reading, mobility, and work-related activities during recovery, even when spontaneous neurological improvement is expected. Incorporating eye movement and convergence exercises provides opportunities for active visual engagement during daily therapy sessions and may support participation while recovery progresses. Prolonged visual disuse has been suggested to negatively influence visual system plasticity [12]. The equipment-free nature of the intervention facilitates implementation across rehabilitation settings without additional resources.Previous studies of oculomotor rehabilitation in patients with brain injury have reported improvements following several weeks of intervention [7-9, 13]. Although the present observations cannot be separated from the natural course of FS, these cases demonstrate that such interventions can be delivered safely and feasibly without adverse events in a recovery rehabilitation ward.Occupational therapists are well-positioned to address diplopia-related difficulties because of their focus on activity performance and participation. In the present cases, oculomotor rehabilitation was integrated into daily therapy without specialized equipment, allowing flexible adjustment to patients’ fatigue, attention, and functional goals. This approach may complement medical management by supporting active visual use during daily activities.Although the present case series does not establish treatment efficacy, it highlights practical considerations for supportive management of diplopia during recovery from Fisher syndrome. Future studies involving larger cohorts or comparative designs may further clarify how such interventions influence functional outcomes, therapy engagement, and patient-reported visual comfort during recovery.This case series is limited by the absence of a control condition and small sample size, precluding conclusions regarding treatment efficacy. Nevertheless, for a rare condition such as FS, sharing practical clinical approaches can inform best practice. These cases highlight considerations for supportive management of diplopia during recovery.ConclusionsOccupational therapy–led oculomotor rehabilitation was safely and feasibly implemented during the recovery phase of Fisher syndrome and was associated with improvements in diplopia-related functional difficulties and daily activity performance. While spontaneous neurological recovery is expected, rehabilitation may play a supportive role in facilitating participation during recovery.References1. C. M. Fisher, “An Unusual Variant of Acute Idiopathic Polyneuritis (Syndrome of Ophthalmoplegia, Ataxia and Areflexia),” N Engl J Med 255 , no. 2 (1956): 57–65. https://doi.org/10.1056/NEJM1956071225502012. C. M. Noioso, L. Bevilacqua, and G. M. Acerra, et al., “Miller Fisher Syndrome: An Updated Narrative Review,” Front Neurol 14 (2023): 1250774. https://doi.org/10.3389/fneur.2023.12507743. M. Mori, S. Kuwabara, T. Fukutake, N. Yuki, and T. 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Clarke, “Amblyopia,” Lancet 367 , no. 9519 (2006): 1343–1351. https://doi.org/10.1016/S0140-6736(06)68581-413. Y. Han and K. J. Ciuffreda, N. Kapoor, “Reading-Related Oculomotor Testing And Training Protocols For Acquired Brain Injury In Humans,”Brain Res Protoc 14, no. 1 (2004): 1–12. https://doi.org/10.1016/j.brainresprot.2004.06.002Figure 1. Photographs showing the eye appearances of the three cases before and after the intervention. Each image depicts the gaze direction corresponding to the most severe impairment: right eye adduction in Case A, right eye abduction in Case B, and left eye adduction in Case C. In all three cases, eye alignment showed marked improvement following therapy.