Reversible Holmes' syndrome complicating cardio-pulmonary resuscitation.

The two cardinal features of the syndrome described by Holmes in 19181,2 are a disorder of ocular movement and a disorder of spatial orientation. The former is manifested by severe problems of ocular fixation and accommodation, such that the patient finds great difficulty in fixing his or her gaze on an object and, having done so, has even greater difficulty in moving the point of fixation to look at something else. This means, for instance, that he cannot follow a moving object with his eyes. The second feature means that the patient has difficulty in orientating objects in three-dimensional space, so that he cannot pour a glass of water without spilling it, and, as in this case, has difficulty in lifting food with a fork or spoon. It can also result in disturbance of topographical memory so that he cannot find his way around, even in familiar surroundings. Other features found in some, but not all of Holmes's original six cases include: hemiparesis, hemisensory loss, speech disorders, visual field defects, visual neglect and apraxia. CASE HISTORY A 57-year-old right-handed housewife was admitted to the coronary care unit following an acute inferior myocardial infarction. Three hours after admission she had the first of a series of four episodes of ventricular fibrillation. During the last of these, she required a period of cardio-pulmonary resuscitation lasting 45 minutes and artificial ventilation for a further 48 hours. It was another four days before a normal level of consciousness was restored. She then complained of being unable to eat because she 'kept missing her food with her fork' and of being unable to read. On examination of the central nervous system there was no weakness, sensory loss, hemianopia, or unilateral neglect. Comprehension of speech and cognition were unimpaired, but she had a nominal dysphasia. When she wore her normal glasses, visual acuity was bilaterally 6/6 though she said that it took several seconds for objects to come into focus. She was able to move her eyes in any direction on command, though if the eyes were fixed on a particular object and a