1
|
Young A, Johnston JL. Pearls & Oy-sters: Ocular Myasthenia Gravis: Central Ocular Motor Signs and Unilateral Visual Loss Caused by the Great Neuro-Ophthalmologic Impersonator. Neurology 2024; 102:e209260. [PMID: 38377456 DOI: 10.1212/wnl.0000000000209260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/08/2024] [Indexed: 02/22/2024] Open
Abstract
Myasthenia gravis (MG) has been described as a great mimicker of other neurologic and ocular motility disorders, including centrally mediated ophthalmoplegia. For example, ocular myasthenia gravis (ocular MG) may cause impaired binocular visual acuity for near vision due to reduced accommodation or for distance vision due to accommodative excess. Notably, accommodative excess due to ocular MG is rare, but may occur with exotropia, with or without diplopia. We report 2 cases of ocular MG: First, a 32-year-old man with exotropia, bilateral hypometric and slowed adducting saccades with dissociated abducting nystagmus, miosis, and decreased distance vision in his right eye; second, a 45-year-old man with similar ocular motor deficits, miosis, and myopia. Both patients showed ocular motor deficits which appeared to localize to the pons but were instead due to ocular MG. Ocular MG should be considered in patients who present with reduced visual acuities due to any disruption in accommodation. Any ocular motor deficit, even if appearing to be centrally mediated or occurring without ptosis, may be caused by ocular MG.
Collapse
Affiliation(s)
- Angela Young
- From the Section of Neurology (A.Y., J.L.J.), Department of Internal Medicine and Department of Ophthalmology (J.L.J.), University of Manitoba; and CIADS Research (J.L.J.), Winnipeg, Canada
| | - Janine L Johnston
- From the Section of Neurology (A.Y., J.L.J.), Department of Internal Medicine and Department of Ophthalmology (J.L.J.), University of Manitoba; and CIADS Research (J.L.J.), Winnipeg, Canada
| |
Collapse
|
2
|
Ruan Z, Sun C, Lang Y, Gao F, Guo R, Xu Q, Yu L, Wu S, Lei T, Liu Y, Zhang M, Li H, Tang Y, Gao T, Gao Y, Lu X, Li Z, Chang T. Development and Validation of a Nomogram for Predicting Generalization in Patients With Ocular Myasthenia Gravis. Front Immunol 2022; 13:895007. [PMID: 35874731 PMCID: PMC9302474 DOI: 10.3389/fimmu.2022.895007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/08/2022] [Indexed: 11/14/2022] Open
Abstract
Background This study aims to develop and validate a nomogram for predicting 1- and 2-year generalization probabilities in patients with ocular myasthenia gravis (OMG). Methods In total, 501 eligible patients with OMG treated at seven tertiary hospitals in China between January 2015 and May 2019 were included. The primary outcome measure was disease generalization. A nomogram for predicting 1- and 2-year generalization probabilities was constructed using a stepwise Cox regression model. Nomogram performance was quantified using C-indexes and calibration curves. Two-year cumulative generalization rates were analyzed using the Kaplan−Meier method for distinct nomogram-stratified risk groups. The clinical usefulness of the nomogram was evaluated using decision curve analysis (DCA). Result The eligible patients were randomly divided into a development cohort (n=351, 70%) and a validation cohort (n=150, 30%). The final model included five variables: sex, onset age, repetitive nerve stimulation findings, acetylcholine receptor antibody test results, and thymic status. The model demonstrated good discrimination (C-indexes of 0.733 and 0.788 in the development and validation cohorts, respectively) and calibration, with good agreement between actual and nomogram-estimated generalization probabilities. Kaplan−Meier curves revealed higher 2-year cumulative generalization rates in the high-risk group than that in the low-risk group. DCA demonstrated a higher net benefit of nomogram-assisted decisions compared to treatment of all patients or none. Conclusion The nomogram model can predict 1- and 2-year generalization probabilities in patients with OMG and stratified these patients into distinct generalization risk groups. The nomogram has potential to aid neurologists in selecting suitable patients for initiating immunotherapy and for enrolment in clinical trials of risk-modifying treatments.
Collapse
Affiliation(s)
- Zhe Ruan
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Chao Sun
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Yanlin Lang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Feng Gao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Rongjing Guo
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Quan Xu
- Department of Thoracic Surgery, Jiangxi Provincial People’s Hospital Affiliated to Nanchang University, Nanchang, China
| | - Liping Yu
- Department of Neurology, Xianyang First People’s Hospital, Xianyang, China
| | - Songdi Wu
- Department of Neurology, Xi'an No.1 Hospital, Xi’an, China
| | - Tao Lei
- Department of Neurology, Xi’an Fourth People’s Hospital, Xi’an, China
| | - Yu Liu
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Min Zhang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Huanhuan Li
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Yonglan Tang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Ting Gao
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Yanwu Gao
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Xiaodan Lu
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Zhuyi Li
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
- *Correspondence: Zhuyi Li, ; Ting Chang,
| | - Ting Chang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
- *Correspondence: Zhuyi Li, ; Ting Chang,
| |
Collapse
|
3
|
Kang L, Wan C. Paraneoplastic syndrome in neuroophthalmology. J Neurol 2022; 269:5272-5282. [PMID: 35779086 DOI: 10.1007/s00415-022-11247-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/19/2022] [Accepted: 06/19/2022] [Indexed: 12/16/2022]
Abstract
Paraneoplastic syndrome is a group of clinical symptoms that occur in the state of systemic malignant tumors. Paraneoplastic syndrome of the nervous system can affect any part of the central and peripheral nervous system and may also affect the eyes. In neuroophthalmology, paraneoplastic syndrome has a variety of manifestations that can affect both the afferent and efferent visual systems. The afferent system may involve the optic nerve, retina and uvea; the efferent system may involve eye movement, neuromuscular joints or involuntary eye movements and pupil abnormalities and may also have other neurological symptoms outside the visual system. This article discusses the clinical manifestations, pathological mechanisms, detection methods and treatment methods of paraneoplastic syndrome in neuroophthalmology. The performance of paraneoplastic syndrome is diverse, the diagnosis is difficult, and the treatment should be considered systematically. Differential diagnosis, optimal evaluation and management of these manifestations is not only the key to treatment but also a challenge.
Collapse
Affiliation(s)
- Longdan Kang
- Department of Ophthalmology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Chao Wan
- Department of Ophthalmology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China.
| |
Collapse
|
4
|
Update on the medial longitudinal fasciculus syndrome. Neurol Sci 2022; 43:3533-3540. [DOI: 10.1007/s10072-022-05967-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 02/22/2022] [Indexed: 11/27/2022]
|
5
|
Introduction. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00001-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
6
|
Kim H, Oh SY. Diagnostic yields and clinical features of ocular myasthenia gravis. Medicine (Baltimore) 2021; 100:e26457. [PMID: 34160444 PMCID: PMC8238339 DOI: 10.1097/md.0000000000026457] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 06/05/2021] [Indexed: 01/04/2023] Open
Abstract
To investigate clinical features and diagnosis process of ocular myasthenia gravis (OMG) in ophthalmology department.A total of 36 patients with ptosis or diplopia who had follow-up for at least 3 months between March 2016 and December 2019 were included in this study. Clinical symptoms of patients and the test results were analyzed. According to the positivity of serologic test, these patients were divided into 2 groups (confirmed OMG and possible OMG with relief of symptoms after antimyasthenic treatment) for comparison.Ptosis was present in 12 (33.33%) patients, diplopia was present in 14 (38.89%) patients, and both ptosis and diplopia were present in 10 (27.78%) patients. Acetylcholine receptor auto-antibody (AchR Ab) was positive in 14 (38.89%) of 36 patients and ice test was positive in 15 (71.43%) of 21 patients with ptosis. Unequivocal response to pyridostigmine was observed in 31 (86.11%) patients. For seropositive cases, AchR Ab titer was significantly higher in the group with 2 clinical symptoms than that in the 1 clinical symptom (P = .011).This study presents the usefulness and diagnostic validity of antimyasthenic treatment for OMG, especially seronegative OMG, with detailed symptom analysis.
Collapse
Affiliation(s)
- Hyuna Kim
- Department of Ophthalmology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul
| | - Shin Yeop Oh
- Department of Ophthalmology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| |
Collapse
|
7
|
Kim KH, Kim SW, Shin HY. Initial Repetitive Nerve Stimulation Test Predicts Conversion of Ocular Myasthenia Gravis to Generalized Myasthenia Gravis. J Clin Neurol 2021; 17:265-272. [PMID: 33835748 PMCID: PMC8053540 DOI: 10.3988/jcn.2021.17.2.265] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 02/03/2021] [Accepted: 02/03/2021] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose A major concern with ocular myasthenia gravis (MG) is the potential conversion to generalized MG. This study was conducted to determine if the repetitive nerve stimulation (RNS) test could predict the conversion from ocular to generalized MG. Methods The RNS test was conducted in a consistent manner on five muscles in the face and limbs in every patient. Subjects were divided into those who remained as ocular MG (ROMG group) and those who experienced conversion to generalized MG during follow-up (GOMG group). Results Conversion to generalized MG occurred in 24 (21.4%) of 112 MG patients with ocular onset. The proportion of patients displaying abnormal decreases in responses in the trapezius, abductor digiti minimi, or flexor carpi ulnaris muscles on the RNS test was higher in the GOMG group (p<0.001, p=0.002, and p<0.001, respectively). The Cox proportional-hazards model revealed that an abnormal result on the RNS test was significantly associated with conversion to generalized MG [hazard ratio (HR)=3.13, 95% confidence interval (CI)=1.18–8.32]. Notably, the HR was higher for abnormal results on the RNS test for the limb muscles, at 5.19 (95% CI=2.09–12.90). Conclusions An abnormal result on the RNS test, especially in the limb muscles, is an independent predictor of the conversion from ocular to generalized MG. Applying the RNS test to limb muscles could be useful for predicting the conversion to generalized MG in patients with ocular onset.
Collapse
Affiliation(s)
- Ki Hoon Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Woo Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
8
|
Comitant Ocular Deviation in Myasthenia Gravis. J Neuroophthalmol 2020; 41:e619-e621. [PMID: 32868571 DOI: 10.1097/wno.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Occurrence of comitant ocular deviation in myasthenia gravis (MG) is not well described. METHODS A retrospective analysis of patients with ocular or generalized MG evaluated at a neuro-ophthalmology clinic for a 6-year period. Comitant ocular deviation was defined as magnitude of deviations in all planes varying by <20% from the measurement in the primary position. RESULTS Among the 120 patients included, 89 patients had ocular and 31 patients generalized MG. At the initial strabismus testing, comitant ocular deviation was present in 27 (22.5%) patients. Among the 16 patients who had a follow-up, ocular deviation remained comitant in 6 patients and converted to incomitant or no ocular deviation in 10 patients. An additional 7 patients demonstrated comitant ocular deviation at follow-up. Brain MRI was performed in 18 patients with comitant ocular deviation, and none showed abnormalities in the brainstem or cerebellum. CONCLUSION Comitant ocular deviation can be an ocular manifestation of MG. Its presence does not necessarily indicate a central etiology in patients with MG neither excluding a MG diagnosis.
Collapse
|
9
|
Wirth MA, Fierz FC, Valko Y, Weber KP. Diagnosing Myasthenia Gravis With Repetitive Ocular Vestibular Evoked Myogenic Potentials. Front Neurol 2020; 11:861. [PMID: 32903498 PMCID: PMC7438439 DOI: 10.3389/fneur.2020.00861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/07/2020] [Indexed: 11/13/2022] Open
Abstract
Timely and accurate diagnosis of myasthenia gravis, particularly in patients with fluctuating, isolated ocular involvement, remains challenging. Serological antibody testing and repetitive nerve stimulation of peripheral muscles usually have low sensitivity in these patients. Edrophonium testing may cause adverse events, single-fiber electromyography (SFEMG) is time-consuming and both tests are often unavailable outside specialized institutions. Repetitive ocular vestibular evoked myogenic potential (roVEMP) stimulation has recently been introduced to facilitate the diagnosis of myasthenia gravis. Similar to repetitive nerve stimulation, roVEMPs detect muscle decrements with the benefit of being non–invasive and allowing for direct measurement of the extraocular muscles. This review summarizes the clinical evidence of the diagnostic value of roVEMP for myasthenia. Prospective clinical trials have demonstrated high sensitivity and specificity. RoVEMPs are of particular interest in challenging myasthenia subgroups with isolated ocular involvement, negative serology, and/or negative conventional electrophysiological results. Optimal roVEMP repetition rates of 20–30 Hz have been identified. This promising novel diagnostic tool merits further attention and investigation to establish its value as a clinical test for myasthenia.
Collapse
Affiliation(s)
- Magdalena A. Wirth
- Department of Ophthalmology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Ophthalmology, University of British Columbia, Vancouver, BC, Canada
| | - Fabienne C. Fierz
- Department of Ophthalmology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Yulia Valko
- Department of Neurology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Konrad P. Weber
- Department of Ophthalmology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- *Correspondence: Konrad P. Weber
| |
Collapse
|
10
|
Marotta DA, Jabaay MJ, Zadourian A, Kesserwani H. Bilateral Orbital Metastases Masquerading as Ocular Myasthenia Gravis: A Case Report and Review of the Literature. Cureus 2020; 12:e9105. [PMID: 32789050 PMCID: PMC7417125 DOI: 10.7759/cureus.9105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Ocular myasthenia gravis and orbital metastases have overlapping symptoms but divergent diagnostic and treatment strategies. Here, we present a 58-year-old female, with a 20-year history of advanced metastatic breast cancer, who presented to the neurology clinic with fatigue, muscle weakness, bilateral ptosis, and diplopia that worsened throughout the day. While the initial presentation was consistent with ocular myasthenia gravis, a subsequent evaluation revealed bilateral metastatic lesions of breast origin within the orbits. This case highlights the variable nature of metastatic disease and underscores the importance of a comprehensive neoplastic workup in patients with new-onset symptomatology and a prior history of advanced cancer despite purported remission status.
Collapse
Affiliation(s)
- Dario A Marotta
- Department of Research, Alabama College of Osteopathic Medicine, Dothan, USA.,Department of Neurology, Division of Neuropsychology, University of Alabama, Birmingham, USA
| | - Maxwell J Jabaay
- Department of Research, Alabama College of Osteopathic Medicine, Dothan, USA
| | - Adena Zadourian
- Department of Research, Alabama College of Osteopathic Medicine, Dothan, USA
| | | |
Collapse
|
11
|
Beatmung bei neuromuskulären Erkrankungen. NEUROLOGISCHE BEATMUNGSMEDIZIN 2020. [PMCID: PMC7236064 DOI: 10.1007/978-3-662-59014-0_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Neuromuskuläre Erkrankungen betreffen das erste und zweite Motoneuron, die peripheren Nerven, die neuromuskulären Übertragung und die Muskelzelle. Es handelt sich um eine heterogene Gruppe von erblichen, degenerativen und autoimmunen Erkrankungen. Eine korrekte diagnostische Einordnung ist erforderlich, da zentralnervöse, kardiale, endokrine und weitere Begleitsymptome vorliegen können und für einige Erkrankungen bereits medikamentöse Therapien zur Verfügung stehen. Neuromuskuläre Erkrankungen haben eine große Bedeutung in der neuromuskulären Beatmungsmedizin. Die respiratorische Symptomatik resultiert in der Regel aus Paresen der am Atmen, Schlucken oder Husten beteiligten Muskulatur mit konsekutiver ventilatorischer Insuffienz, Dysphagie bis hin zur Speichelaspiration und Sekretretention. Mittels eines strukturierte Sekretmanagements und einer effektive nichtinvasive oder invasive Beatmungstherapie können neuromuskuläre Patienten viele Jahre mit guter Lebensqualität überleben. Themen dieses Kapitels sind ein Überblick über die neuromuskulären Erkrankungen, die Indikationen und Strategien der nichtinvasiven und der invasiven Beatmung und eine ausführliche Darstellung beatmungsmedizinisch besonders relevanter neuromuskulärer Erkrankungen wie der amyotrophe Lateralsklerose, des Guillain-Barré-Syndroms, der Myasthenia gravis und der Critical-Illness-Polyneuropathie/-Myopathie.
Collapse
|
12
|
Dagi LR, Velez FG, Archer SM, Atalay HT, Campolattaro BN, Holmes JM, Kerr NC, Kushner BJ, Mackinnon SE, Paysse EA, Pihlblad MS, Pineles SL, Strominger MB, Stager DR, Stager D, Capo H. Adult Strabismus Preferred Practice Pattern®. Ophthalmology 2020; 127:P182-P298. [DOI: 10.1016/j.ophtha.2019.09.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 09/20/2019] [Indexed: 11/25/2022] Open
|
13
|
Saluja G, Samdani A, Bhatia P. Importance of clinical tests in ocular myasthenia. BMJ Case Rep 2019; 12:12/12/e231296. [PMID: 31818887 DOI: 10.1136/bcr-2019-231296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 24-year-old otherwise healthy male presented to us with unilateral ptosis and contralateral lid retraction with limitation of extraocular movements; the disease had a gradual chronic course, which raised a suspicion of ocular myasthenia. Ice pack test was performed, which improved the ptosis; further investigations confirmed the diagnosis of ocular myasthenia. Patient was started on pyridostigmine and oral prednisolone which improved the extraocular movements and ptosis.
Collapse
Affiliation(s)
- Gunjan Saluja
- Strabismus and Neuro-ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Asha Samdani
- Strabismus and Neuro-ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Priyavrat Bhatia
- Vitreo-Retina, Sadguru Netra Chikitsalaya, Chitrakoot, Madhya Pradesh, India
| |
Collapse
|
14
|
Repetitive ocular vestibular evoked myogenic potential stimulation for the diagnosis of myasthenia gravis: Optimization of stimulation parameters. Clin Neurophysiol 2019; 130:1125-1134. [DOI: 10.1016/j.clinph.2019.03.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 03/17/2019] [Accepted: 03/30/2019] [Indexed: 11/24/2022]
|
15
|
Kee HJ, Yang HK, Hwang JM, Park KS. Evaluation and validation of sustained upgaze combined with the ice-pack test for ocular myasthenia gravis in Asians. Neuromuscul Disord 2019; 29:296-301. [DOI: 10.1016/j.nmd.2018.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/28/2018] [Accepted: 12/18/2018] [Indexed: 11/29/2022]
|
16
|
Merino Sanz P, Del Cerro Pérez I, Alan Peinado G, Gómez de Liaño Sánchez P. Causes and surgical treatment of diplopia and strabismus secondary to myasthenia gravis. ACTA ACUST UNITED AC 2018; 94:107-113. [PMID: 30580990 DOI: 10.1016/j.oftal.2018.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/08/2018] [Accepted: 11/13/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To present a report of the ocular motility disorders, treatment and outcomes of myasthenia gravis (MG). MATERIAL AND METHOD A retrospective study was performed on the data of patients with MG. An evaluation was made using mean age, gender, initial diagnosis, ocular deviation, time of onset of clinical characteristics, treatment and results. Resolution of diplopia and/or ocular deviation in primary and reading gaze was considered a good outcome at the end of follow-up. RESULTS A total of 14 cases were included. The mean age of the sample was 55.64 years, of which 9 were women, and 10 cases were bilateral. The diagnosis was made by ophthalmologists in 4 cases. The initial diagnoses were diverse: bilateral cranial third nerve palsy in 3, unilateral third nerve palsy in 1, superior or inferior rectus palsy in 3, sixth nerve palsy in 2, fourth nerve palsy in 1, exotropia in 3 and esotropia in 1. Diplopia was presented in 14 cases and 9 associated ptosis. The different types of strabismus were horizontal ocular deviation in 11 cases: 8 with exotropia, and 4 with vertical deviation. Strabismus surgery was performed in 4 cases that did not respond to medical treatment, with a good final outcome. Pharmacological treatment resolved diplopia in 6 cases, and prisms in one. Ptosis surgery was only necessary in one patient. Outcome was favourable in 78.57% at the end of follow-up. CONCLUSION Acute onset diplopia caused by strabismus with variable angle or oculomotor palsy, associated or not with a ptosis can indicate MG. There were favourable outcomes with strabismus surgery. Pharmacological treatment did not resolve the diplopia in all cases.
Collapse
Affiliation(s)
- P Merino Sanz
- Sección de Motilidad Ocular, Departamento de Oftalmología, HGU Gregorio Marañón, Madrid, España.
| | - I Del Cerro Pérez
- Sección de Motilidad Ocular, Departamento de Oftalmología, HGU Gregorio Marañón, Madrid, España
| | - G Alan Peinado
- Sección de Motilidad Ocular, Departamento de Oftalmología, HGU Gregorio Marañón, Madrid, España
| | | |
Collapse
|
17
|
Blanc C, Bidot S, Héran F, Tournaire-Marques É, Vignal-Clermont C. A Puzzling Ocular Motility Disorder: Apparent Up-Gaze Fatigability in a Patient With Oculomotor Nerve Compression. Neuroophthalmology 2018; 42:242-245. [PMID: 30042796 DOI: 10.1080/01658107.2017.1374416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 08/23/2017] [Accepted: 08/29/2017] [Indexed: 10/18/2022] Open
Abstract
We report the case of a woman who developed right third nerve dysfunction with synkinesis and ocular neuromyotonia secondary to a compressive arterial aneurysm. Surprisingly, our examination showed a downward drift of the right eye in sustained up-gaze resulting in transient hypotropia, suggesting either fatigability of the superior rectus or contraction of the inferior rectus. We believe this ocular motility pattern is secondary to a co-contraction of the inferior rectus in up-gaze caused by synkinesis (explaining the downward drift), followed by failure of the inferior rectus to relax upon return to primary position caused by ocular neuromyotonia (explaining the hypotropia).
Collapse
Affiliation(s)
- Christelle Blanc
- Department of Neurology, University Hospital of Dijon, Dijon, France
| | - Samuel Bidot
- Department of Ophthalmology, The Rothschild Foundation, Paris, France
| | - Françoise Héran
- Department of Radiology and Imaging Sciences, The Rothschild Foundation, Paris, France
| | | | | |
Collapse
|
18
|
Ahn J, Park KS, Kim JS, Hwang JM. Efficacy of Gaze Photographs in Diagnosing Ocular Myasthenia Gravis. J Clin Neurol 2018; 14:333-338. [PMID: 29856158 PMCID: PMC6031998 DOI: 10.3988/jcn.2018.14.3.333] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 02/20/2018] [Accepted: 02/20/2018] [Indexed: 11/24/2022] Open
Abstract
Background and Purpose The various tests that are routinely used to diagnose generalized myasthenia gravis, such as the edrophonium test, serum anti-acetylcholine-receptor antibodies (AChR-Ab), and repetitive nerve stimulation (RNS) tests, have lower diagnostic sensitivity in ocular myasthenia gravis (OMG). Diagnosing OMG becomes even more difficult when the clinical symptoms are subtle. There is no gold-standard diagnostic test available for OMG patients, and so this study compared the diagnostic sensitivity of gaze photographs with conventional tests in OMG. Methods Records of gaze photographs were available for 25 of 31 consecutive patients diagnosed with OMG. Each patient underwent a neuro-ophthalmologic examination, serum AChR-Ab, RNS, edrophonium test, ice tests, and the acquisition of gaze photographs. The margin reflex distance 1 (MRD1) was measured on each of the gaze photographs, with MRD1 <2 mm or an interlid MRD1 difference of ≥2 mm on any of the gaze photographs defined as a positive sign of OMG. The diagnostic sensitivities of the tests were assessed. Results The mean age at onset was 38.5 years (range, 2–76 years), and 13 patients (52%) were men. The diagnostic sensitivities of the RNS test, AChR-Ab test, gaze photographs, and ice test were 56%, 64%, 80%, and 73%, respectively. Conclusions The diagnostic sensitivity was higher for gaze photographs than for the other tests applied to OMG patients.
Collapse
Affiliation(s)
- Jeeyun Ahn
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea.,Department of Ophthalmology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Kyung Seok Park
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea.,Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea.,Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong Min Hwang
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea.,Department of Ophthalmology, Seoul National University Bundang Hospital, Seongnam, Korea.
| |
Collapse
|
19
|
Teo KY, Tow SL, Haaland B, Gosavi TD, Jing-Liang L, Yew Long LO, Milea D. Low conversion rate of ocular to generalized myasthenia gravis in Singapore. Muscle Nerve 2017; 57:756-760. [PMID: 28981152 DOI: 10.1002/mus.25983] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Ocular myasthenia gravis (OMG) is a common condition of the neuromuscular junction that may convert to generalized myasthenia gravis (GMG). Our aim in this study was to determine the conversion rate and predictive factors for generalization in OMG, in an Asian population. METHODS The investigation consisted of a retrospective study of OMG patients with a minimum 2 years of follow-up. RESULTS Among 191 patients with OMG, 155 had the minimum 2-year follow-up. The conversion rate at median follow-up (40.8 months) was 10.6% (95% confidence interval 7.9%-13.3%), and at the 2-year follow-up it was 7.7% (95% confidence interval 5.6%-9.8%). At baseline, the predictive factors for generalization were positive acetylcholine receptor antibodies (hazard ratio 3.71, P = 0.024), positive repetitive nerve stimulation (RNS) studies (hazard ratio 4.42, P = 0.003), and presence of radiologically presumed or pathologically confirmed thymoma (hazard ratio 3.10, P = 0.013). DISCUSSION The conversion rate of OMG to GMG in Asian patients is low, as predicted by presence of acetylcholine receptor antibodies, presence of thymoma, and positive RNS studies. Muscle Nerve 57: 756-760, 2018.
Collapse
Affiliation(s)
| | - Sharon L Tow
- Singapore National Eye Centre, Singapore Eye Research Institute and Duke-NUS, Singapore
| | - Benjamin Haaland
- Population Health Sciences, University of Utah, USA and Duke-NUS, Singapore
| | - Tushar D Gosavi
- National Neuroscience Institute, Singapore General Hospital, Singapore
| | - Loo Jing-Liang
- Singapore National Eye Centre, Singapore Eye Research Institute, Yong Yoo Lin Medical School and Duke-NUS
| | - L O Yew Long
- National Neuroscience Institute, Singapore General Hospital, Singapore
| | - Dan Milea
- Singapore National Eye Centre, Singapore Eye Research Institute and Duke-NUS, Singapore
| |
Collapse
|
20
|
Diplopia. Neurologia 2017. [DOI: 10.1016/s1634-7072(17)86802-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
21
|
Park JY, Yang HK, Hwang JM. Diagnostic value of repeated ice tests in the evaluation of ptosis in myasthenia gravis. PLoS One 2017; 12:e0177078. [PMID: 28562609 PMCID: PMC5451013 DOI: 10.1371/journal.pone.0177078] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 04/21/2017] [Indexed: 12/04/2022] Open
Abstract
Twenty-six patients with ptosis related to Myasthenia gravis (MG) and 38 controls with ptosis other than MG were included. All patients were tested with the ice test 2 times on separate days in the afternoon. The margin reflex distance (MRD) was measured before and immediately after 2-minute application of ice on the eyelids. The ice test was judged positive if there was an improvement of at least 2.0 mm of MRD after the ice test. Among the patients with negative test results, 'equivocal' was defined by improvement of MRD from at least 1.0 mm to less than 2.0 mm after the ice test. Repeated ice test results showed an agreement of 61.5% in MG, and 97.4% in nonmyasthenic ptosis. Repeated ice tests increased the sensitivity by 34.6% compared to a single test. Among the patients with repeatedly negative test results, 63.6% of those who showed equivocal results at least once turned out to be MG. Of those with repeated non-equivocal negative results, nobody turned out to be MG. There was no significant difference of the ice test results between ocular MG and generalized MG (p = 0.562).
Collapse
Affiliation(s)
- Jun Young Park
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Hee Kyung Yang
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Jeong-Min Hwang
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| |
Collapse
|
22
|
Affiliation(s)
- Ghislaine L Traber
- From the Departments of Ophthalmology (G.L.T., Y.V., R.G., K.PW.) and Neurology (Y.V., K.PW.), University Hospital Zurich, University of Zurich, Switzerland.
| | - Yulia Valko
- From the Departments of Ophthalmology (G.L.T., Y.V., R.G., K.PW.) and Neurology (Y.V., K.PW.), University Hospital Zurich, University of Zurich, Switzerland
| | - Renata Gulik
- From the Departments of Ophthalmology (G.L.T., Y.V., R.G., K.PW.) and Neurology (Y.V., K.PW.), University Hospital Zurich, University of Zurich, Switzerland
| | - Konrad P Weber
- From the Departments of Ophthalmology (G.L.T., Y.V., R.G., K.PW.) and Neurology (Y.V., K.PW.), University Hospital Zurich, University of Zurich, Switzerland
| |
Collapse
|
23
|
A young woman with ptosis. JAAPA 2017; 30:53-55. [DOI: 10.1097/01.jaa.0000513354.45524.f0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
24
|
Bidot S, Biousse V. [Diplopia: An important symptom in internal medicine!]. Rev Med Interne 2017; 38:806-816. [PMID: 28325621 DOI: 10.1016/j.revmed.2017.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 01/21/2017] [Indexed: 11/25/2022]
Abstract
Diplopia is defined as "double vision" when looking at a single object. Monocular diplopia is related to an ocular disorder and must be differentiated from binocular diplopia which is secondary to ocular misalignment. The examination of the patient with binocular diplopia is often challenging for non-specialists. However, a careful and systematic clinical examination followed by targeted ancillary testing allows the clinician to localize the lesion along the oculomotor pathways. The lesion may involve the brainstem, the ocular motor nerves III, IV or VI, the neuromuscular junction, the extraocular ocular muscles, or the orbit. Causes of binocular diplopia are numerous and often include disorders typically managed by internal medicine such as inflammatory, infectious, neoplastic, endocrine, and metabolic disorders. In addition to treating the underlying disease, it is important not to leave diplopia uncorrected. Temporary occlusion of one eye by applying tape on one lens or patching one eye relieves the diplopia until more specific treatments are offered should the diplopia not fully resolve.
Collapse
Affiliation(s)
- S Bidot
- Fondation ophtalmologique Adolphe-de-Rothschild, 75019 Paris, France; Centre hospitalier national d'ophtalmologie des Quinze-Vingts, 75571 Paris, France
| | - V Biousse
- Services d'ophtalmologie et de neurologie, Emory university school of medicine, Atlanta, GA, États-Unis.
| |
Collapse
|
25
|
Nair AG, Patil-Chhablani P, Venkatramani DV, Gandhi RA. Ocular myasthenia gravis: a review. Indian J Ophthalmol 2016; 62:985-91. [PMID: 25449931 PMCID: PMC4278125 DOI: 10.4103/0301-4738.145987] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Myasthenia gravis (MG) is a disease that affects the neuro-muscular junction resulting in classical symptoms of variable muscle weakness and fatigability. It is called the great masquerader owing to its varied clinical presentations. Very often, a patient of MG may present to the ophthalmologist given that a large proportion of patients with systemic myasthenia have ocular involvement either at presentation or during the later course of the disease. The treatment of ocular MG involves both the neurologist and ophthalmologist. Thus, the aim of this review was to highlight the current diagnosis, investigations, and treatment of ocular MG.
Collapse
Affiliation(s)
| | - Preeti Patil-Chhablani
- Department of Strabismus and Neuro-Ophthalmology, Jasti V Ramanamma Children's Eye Care Centre, Hyderabad, Telangana, India
| | | | | |
Collapse
|
26
|
Caignard A, Leruez S, Milea D. Urgences en neuro-ophtalmologie. J Fr Ophtalmol 2016; 39:716-728. [DOI: 10.1016/j.jfo.2016.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 04/27/2016] [Accepted: 05/25/2016] [Indexed: 11/30/2022]
|
27
|
Laboratory Investigations for Diagnosis of Autoimmune and Inflammatory Periocular Disease: Part I. Ophthalmic Plast Reconstr Surg 2016; 32:321-8. [DOI: 10.1097/iop.0000000000000697] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
28
|
Mashige KP, Munsamy AJ. Diplopia. S Afr Fam Pract (2004) 2016. [DOI: 10.1080/20786190.2014.978100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
|
29
|
Mangaraj S, Choudhury AK, Mohanty BK, Baliarsinha AK. Neurological manifestations of Graves' disease: A case report and review of the literature. J Neurosci Rural Pract 2016; 7:153-6. [PMID: 26933368 PMCID: PMC4750319 DOI: 10.4103/0976-3147.165393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Graves’ disease (GD) is characterized by a hyperfunctioning thyroid gland due to stimulation of the thyroid-stimulating hormone receptor by autoantibodies directed against it. Apart from thyrotoxicosis, other clinical manifestations include ophthalmopathy, dermopathy, and rarely acropachy. GD is an organ-specific autoimmune disorder, and hence is associated with various other autoimmune disorders. Myasthenia gravis (MG) is one such disease, which is seen with patients of GD and vice versa. Though the association of GD and myasthenia is known, subtle manifestations of latter can be frequently missed in routine clinical practice. The coexistence of GD and ocular MG poses a significant diagnostic dilemma to treating physicians. The ocular manifestations of myasthenia can be easily missed in case of GD and falsely attributed to thyroid associated ophthalmopathy due to closely mimicking presentations of both. Hence, a high degree of the clinical vigil is necessary in such cases to appreciate their presence. We present a similar case which exemplifies the above said that the clinical challenge in diagnosing coexistent GD and ocular myasthenia.
Collapse
Affiliation(s)
| | | | - Binoy Kumar Mohanty
- Department of Endocrinology, S. C. B Medical College, Cuttack, Odisha, India
| | | |
Collapse
|
30
|
|
31
|
|
32
|
Zambelis T, Pappas V, Kokotis P, Zouvelou V, Karandreas N. Patients with ocular symptoms referred for electrodiagnosis: how many of them suffer from myasthenia gravis? Acta Neurol Belg 2015; 115:671-4. [PMID: 25822064 DOI: 10.1007/s13760-015-0460-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Accepted: 03/16/2015] [Indexed: 11/28/2022]
Abstract
The aim of this study was the diagnosis of patients with isolated ocular manifestations (ptosis and/or diplopia) referred for electrophysiological evaluation to the electrodiagnostic laboratory of a University Neurological Department. Examination was performed either in inpatient status or in outpatient basis. We analyzed the clinical, electrophysiological and other laboratory data in 79 subjects. Myasthenia gravis (MG) was diagnosed in 38 %, 45.6 % in other diseases (Graves disease, blepharospasm, IIId cranial verve palsy, multiple sclerosis, stroke, etc.), while in 16.5 %, the cause remained unidentified. Symptoms fluctuation was significantly more frequent in the myasthenic patients, compared to patients with other diseases. The presence of both diplopia and ptosis are more likely due to MG rather than other pathology.
Collapse
Affiliation(s)
- Th Zambelis
- Department of Neurology, EMG Laboratory, University of Athens, Aeginition Hospital, 74, Vass. Sofias Ave., 115-28, Athens, Greece.
| | - V Pappas
- Department of Neurology, EMG Laboratory, University of Athens, Aeginition Hospital, 74, Vass. Sofias Ave., 115-28, Athens, Greece
| | - P Kokotis
- Department of Neurology, EMG Laboratory, University of Athens, Aeginition Hospital, 74, Vass. Sofias Ave., 115-28, Athens, Greece
| | - V Zouvelou
- Department of Neurology, EMG Laboratory, University of Athens, Aeginition Hospital, 74, Vass. Sofias Ave., 115-28, Athens, Greece
| | - N Karandreas
- Department of Neurology, EMG Laboratory, University of Athens, Aeginition Hospital, 74, Vass. Sofias Ave., 115-28, Athens, Greece
| |
Collapse
|
33
|
|
34
|
Seo EJ, Park A, Chung SA. Two Cases with Positive Ice Tests Mimicking Ocular Myasthenia Gravis. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2015. [DOI: 10.3341/jkos.2015.56.2.309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Eoi Jong Seo
- Department of Ophthalmology, Ajou University School of Medicine, Suwon, Korea
| | - Aram Park
- Department of Ophthalmology, Ajou University School of Medicine, Suwon, Korea
| | - Seung Ah Chung
- Department of Ophthalmology, Ajou University School of Medicine, Suwon, Korea
| |
Collapse
|
35
|
Kerty E, Elsais A, Argov Z, Evoli A, Gilhus NE. EFNS/ENS Guidelines for the treatment of ocular myasthenia. Eur J Neurol 2014; 21:687-93. [PMID: 24471489 DOI: 10.1111/ene.12359] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 12/17/2013] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE The symptoms of acquired autoimmune ocular myasthenia are restricted to the extrinsic eye muscles, causing double vision and drooping eyelids. These guidelines are designed to provide advice about best clinical practice based on the current state of clinical and scientific knowledge and the consensus of an expert panel. SEARCH STRATEGY Evidence for these guidelines was collected by searches in the MEDLINE and Cochrane databases. The task force working group reviewed evidence from original articles and systematic reviews. The evidence was classified (I, II, III, IV) and consensus recommendation graded (A, B or C) according to the EFNS guidance. Where there was a lack of evidence but clear consensus, good practice points are provided. CONCLUSIONS The treatment of ocular myasthenia should initially be started with pyridostigmine (good practice point). If this is not successful in relieving symptoms, oral corticosteroids should be used on an alternate-day regimen (recommendation level C). If steroid treatment does not result in good control of the symptoms or if it is necessary to use high steroid doses, steroid-sparing treatment with azathioprine should be started (recommendation level C). If ocular myasthenia gravis is associated with thymoma, thymectomy is indicated. Otherwise, the role of thymectomy in ocular myasthenia is controversial. Steroids and thymectomy may modify the course of ocular myasthenia and prevent myasthenia gravis generalization (good practice point).
Collapse
Affiliation(s)
- E Kerty
- Department of Neurology, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | | | | | | |
Collapse
|
36
|
Park KA, Oh SY. Current treatment for ocular myasthenia gravis. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.2013.851003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
37
|
Arora Y, Li Y. Overview of myasthenia gravis. Hosp Pract (1995) 2013; 41:40-50. [PMID: 24145588 DOI: 10.3810/hp.2013.10.1079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Myasthenia gravis is an antibody-mediated disorder of neuromuscular transmission that is characterized by weakness and fatigue of voluntary muscles. Weakness may be ocular, bulbar, or generalized. Diagnostic evaluation of patients consists of bedside assessment, antibody testing, and electrophysiologic studies. Various therapeutic options are available, which consist of anticholinesterase inhibitors for symptomatic management, immunosuppressive agents as maintenance therapy, and thymectomy. Plasmapheresis and intravenous immunoglobulin are used in patients in crisis or those with rapidly worsening or refractory symptoms. In our article, we elaborate on key aspects of the epidemiology, pathogenesis, diagnostic evaluation, and therapeutic options for patients with myasthenia gravis.
Collapse
Affiliation(s)
- Yeeshu Arora
- Division of the Neuromuscular Center, Department of Neurology, Cleveland Clinic, Cleveland, OH
| | | |
Collapse
|
38
|
Abstract
PURPOSE OF REVIEW To review ocular myasthenia gravis (OMG), a localized form of myasthenia gravis clinically involving only the extraocular, levator palpebrae superioris, and orbicularis oculi muscles. RECENT FINDINGS Ocular manifestations can masquerade as a variety of ocular motility disorders, including central nervous system disorders and peripheral cranial nerve palsies. While sparing the pupils, the diagnosis and management can be challenging. SUMMARY Because several diagnostic and treatment options are available for OMG, clinicians must decide the sequence and combination based on the level of disease activity and patient disability.
Collapse
|
39
|
Abstract
Monocular elevation deficiency is the inability to elevate the eye in abduction and adduction. Myasthenia gravis could mimic any pattern of ophthalmoplegia. However, myasthenia gravis mimicking monocular elevation deficiency appears to be very rare. A 12-month-old girl presented with the inability to elevate the left eye and blepharoptosis from 3 months of age. A neostigmine test showed a weakly positive response. Repetitive stimulation of the left orbicularis oculi produced no decremental response. Three assays for acetylcholine receptor antibodies were negative. Placing ice over the lids definitely improved left blepharoptosis. In conclusion, myasthenia gravis could mimic elevation deficiency. An ice test could be very helpful in making the diagnosis. Myasthenia gravis should be included in the differential diagnosis of monocular elevation deficiency even at a young age.
Collapse
Affiliation(s)
- Changwon Kee
- Department of Ophthalmology, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | | | | | | |
Collapse
|
40
|
Treatment for diplopia in patients with myasthenia gravis. Graefes Arch Clin Exp Ophthalmol 2012; 251:895-901. [PMID: 23275035 DOI: 10.1007/s00417-012-2227-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 11/01/2012] [Accepted: 11/26/2012] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND The purpose of this study was to describe the treatment experiences and outcomes of patients with myasthenia gravis (MG) whose initial presenting symptom was diplopia METHODS A retrospective review was performed on a group of patients with MG whose initial presenting symptom was diplopia. RESULTS The mean age of onset was 45.5 ± 16.9 years, and the mean follow-up period was 45.4 ± 39.7 months. Exotropia with vertical heterotropia was the most common type of deviation. The mean horizontal deviation was 20.1 ± 17.9 prism diopters, and the mean vertical deviation was 14.8 ± 11.1 prism diopters. Limitation of eye movement was found in 20 patients (71.4 %) during the follow-up period. After conventional treatment for MG, six patients (21.4 %) showed a good response with resolution of diplopia. Four patients (14.3 %) showed a partial response to treatment. Eighteen patients (64.3 %) showed minimal or no response; among them, ten (35.7 %) had an angle of deviation of 15 prism diopters or more. Six patients underwent strabismus surgery. Four were symptom free, and satisfactorily aligned after surgical treatment. One patient had intermittent diplopia despite the small amount of deviation, and one patient experienced recurrence of exotropia with diplopia during the 10-year follow-up. In multivariable analysis, the only factor associated with the need for strabismus surgery was the initial angle of deviation (p = 0.016). CONCLUSIONS Patients with MG who have a larger angle of deviation at presentation tend to require strabismus surgery after stabilization of the disease. Strabismus surgery is one treatment option for patients with MG who have a large angle of deviation and respond poorly to conventional treatment.
Collapse
|
41
|
Shi QG, Wang ZH, Ma XW, Zhang DQ, Yang CS, Shi FD, Yang L. Clinical significance of detection of antibodies to fetal and adult acetylcholine receptors in myasthenia gravis. Neurosci Bull 2012; 28:469-74. [PMID: 22961471 DOI: 10.1007/s12264-012-1256-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 05/23/2012] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate the frequency, distribution and clinical significance of the antibodies to the fetal and/or adult acetylcholine receptor (AChR) in patients with myasthenia gravis (MG). METHODS AChR antibodies were detected by cell-based assay in the serum of ocular MG (OMG) (n = 90) and generalized MG (GMG) patients (n = 110). The fetal-type (2α: β: γ: δ) and adult-type (2α: β: ε: δ) AChR were used as antigens, and their relevance to disease presentation was assessed. RESULTS The overall frequencies of anti-adult and anti-fetal AChR antibodies were similar in all 200 patients examined, with 14 having serum specific to the AChR-Γ subunit, and 22 to the AChR-ε subunit. The overall sensitivity when using the fetal and adult AChR antibodies was higher than that when using the fetal AChR antibody only (P = 0.015). Compared with OMG patients, the mean age at disease onset and the positive ratio of antibodies to both isoforms of the AChR were significantly higher in patients who subsequently progressed to GMG. Older patients and patients with both anti-fetal and anti-adult AChR antibodies had a greater risk for developing generalized disease [odds ratio (OR), 1.03; 95% confidence interval (CI), 1.01-1.06 and OR, 5.09; 95% CI, 2.23-11.62]. CONCLUSION Using both fetal- and adult-type AChRs as the antigens may be more sensitive than using either subtype. Patients with serum specific to both isoforms are at a greater risk of progressing to GMG. Patients with disease onset at an advanced age appear to have a higher frequency of GMG conversion.
Collapse
Affiliation(s)
- Qi-Guang Shi
- Department of Neurology and Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | | | | | | | | | | | | |
Collapse
|
42
|
Wu X, Tuzun E, Li J, Xiao T, Saini SS, Qi H, Allman W, Christadoss P. Ocular and generalized myasthenia gravis induced by human acetylcholine receptor γ subunit immunization. Muscle Nerve 2012; 45:209-16. [DOI: 10.1002/mus.22273] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
43
|
Myasthénies oculaires : diagnostic et traitement. Rev Neurol (Paris) 2010; 166:987-97. [DOI: 10.1016/j.neurol.2010.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Revised: 07/10/2010] [Accepted: 08/31/2010] [Indexed: 11/18/2022]
|
44
|
Abbott SA. Diagnostic challenge: Myasthenia gravis in the emergency department. JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 2010; 22:468-73. [PMID: 20854638 DOI: 10.1111/j.1745-7599.2010.00541.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To describe an instructive case of neurological disease encountered by a nurse practitioner (NP) student in the emergency department (ED). Characteristics, epidemiology, pathophysiology, diagnostic considerations, and appropriate testing options for myasthenia gravis (MG) are included. DATA SOURCES Findings from the history, physical examination, and diagnostic testing of a 41-year-old male with neck weakness and pain. Review of published literature about MG. CONCLUSIONS MG is a pure motor syndrome characterized by fluctuating muscle weakness and fatigue and is exacerbated by sustained muscle use. It is usually caused by an autoimmune process that is chronic and progressive. Multiple patient encounters with the healthcare system often occur prior to diagnosis. Many viable treatment options now exist that can enhance quality of life and improve function. IMPLICATIONS FOR PRACTICE The NP must include MG in the differential diagnosis with any report of fluctuating muscle weakness or other neurological, upper gastrointestinal, respiratory, or ophthalmic complaint. The key diagnostic finding is a specific muscle weakness that can be reproduced and exacerbated with sustained muscle use. These considerations will lead to earlier diagnosis and treatment.
Collapse
Affiliation(s)
- Susan A Abbott
- Family and Community Nurse Practitioner Program, Husson University, Bangor, Maine, USA.
| |
Collapse
|
45
|
Kang HM, Park MJ, Hwang JM, Kim JW, Jeong SH. Development of ocular myasthenia during pegylated interferon and ribavirin treatment for chronic hepatitis C. THE KOREAN JOURNAL OF HEPATOLOGY 2009; 15:209-15. [PMID: 19581773 DOI: 10.3350/kjhep.2009.15.2.209] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A 63-year-old male experienced sudden diplopia after 9 weeks of administration of pegylated interferon (IFN) alpha-2b and ribavirin for chronic hepatitis C (CHC). Ophthalmologic examinations showed ptosis on the right upper lid and restricted right eye movement without any other neurological signs. A brain imaging study and repetitive nerve stimulation test indicated no abnormality. The acetylcholine receptor antibody titer and response to acetylcholinesterase inhibitors were negative, and the results of thyroid function tests were normal. The patient's ophthalmological symptoms improved rapidly 3 weeks after discontinuation of pegylated IFN alpha-2b and ribavirin. The ocular myasthenia associated with combination therapy of pegylated IFN alpha-2b and ribavirin for CHC is very rarely reported; therefore, we present this case with a review of the various eye complications of IFN therapy.
Collapse
Affiliation(s)
- Hyung Min Kang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | | | | | | | | |
Collapse
|
46
|
Abstract
PURPOSE OF REVIEW Increasing rigor is being applied to medical decision making, but myasthenia gravis, commonly considered the best understood autoimmune disorder from a pathophysiological basis, lags other disciplines in the evidence base used to make clinical decisions. The review attempts to provide a focused, practical guideline for the diagnosis and treatment of ocular myasthenia within the limits of largely retrospective case series and expert opinion. RECENT FINDINGS Confirmation of clinical diagnosis continues to be challenging for ocular myasthenia. Despite the recognition of a new autoantigen, the muscle-specific kinase protein in generalized myasthenia gravis, it has been found to be only rarely identified in ocular myasthenia patients and therefore the majority of patients lack detectable autoantibodies and confirmation of a neuromuscular transmission disorder relies on specialized testing of single-fiber electromyography. The visual compromise of ocular myasthenia responds poorly to nonpharmacological and cholinesterase inhibitor therapy, and although corticosteroids are thought to be extremely effective, their toxicity is poorly defined in ocular myasthenia patients and whether they reduce the risk of development of generalized disease is not known. SUMMARY Rigorous clinical trials or large databases with outcome assessments are necessary in order to allow development of rational treatment strategies.
Collapse
|
47
|
Abstract
Neuro-ophthalmologic disorders arise from all areas of the neuro-ophthalmologic tract. They may be expressed simply as loss of vision or double vision, or as complex syndromes or systemic illnesses, depending on the location and type of lesion. Problems may occur anywhere along the visual pathway, including the brainstem, cavernous sinus, subarachnoid space, and orbital apex, and may affect adjacent structures also. A firm understanding of the neuroanatomy and neurophysiology of the eye is essential to correct diagnosis.
Collapse
Affiliation(s)
- David K Duong
- Emergency Medicine Residency, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA
| | | | | |
Collapse
|
48
|
Khanna S, Liao K, Kaminski HJ, Tomsak RL, Joshi A, Leigh RJ. Ocular myasthenia revisited: Insights from pseudo-internuclear ophthalmoplegia. J Neurol 2007; 254:1569-74. [PMID: 17713827 DOI: 10.1007/s00415-007-0591-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Revised: 03/01/2007] [Accepted: 03/13/2007] [Indexed: 10/22/2022]
Abstract
Ocular myasthenia can mimic central disorders of eye movements. We compared horizontal saccades in two patients with myasthenia gravis who presented as pseudo-internuclear ophthalmoplegia (pseudo-INO), two patients with true INO due to multiple sclerosis (MS), and five healthy subjects. In myasthenics, peak velocity of horizontal saccades was similar to, or greater than, controls; in MS patients, adducting saccades were slower than controls. Differences between the peak velocity of abducting and adducting eyes for each saccade were similar to controls for myasthenic pseudo-INO, but greater than controls for true INO. Using the technique of phase-plane analysis, in which eye velocity is plotted against eye position, we found that initial components of abducting and adducting saccades in the myasthenics were as conjugate as controls, even though later components of myasthenic saccades were highly and variably disjunctive. Conversely, phase planes of saccades in true INO showed disjunctive early components of abducting and adducting saccades. Two hypotheses have been offered to account for preservation of fast saccades despite reduced range of eye movements in ocular myasthenia. The first is intrasaccadic neuromuscular fatigue, which is variable over time. Our finding that initial components of saccades were consistently conjugate in the myasthenics gives support to a second hypothesis: selective sparing of pale global fibers, which are important for generating highspeed eye movements, and which are unique amongst extraocular fibers in possessing well developed synaptic folding.
Collapse
Affiliation(s)
- Sangeeta Khanna
- Daroff-Dell'Osso Laboratory, Department of Neurology, Veterans Affairs Medical Center and University Hospitals Case Western Reserve University, Cleveland, Ohio 44106, USA
| | | | | | | | | | | |
Collapse
|
49
|
Abstract
BACKGROUND Although myasthenia gravis (MG) is often considered the best-understood autoimmune disorder and effective treatments have controlled life-threatening complications, the pathogenesis of ocular myasthenia (OM) remains enigmatic, and its clinical consequences offer therapeutic challenges. REVIEW SUMMARY About half of patients with MG present with visual complaints of droopy eyelids or double vision, and many will remain with purely ocular muscle weakness without generalized weakness, defined as OM. OM may be confused with disorders of the brainstem, ocular motor nerves, and eye muscles. Frustrating for the clinician, confirmatory tests such as the edrophonium test, serum acetylcholine receptor antibodies, and standard electrodiagnostic evaluations may fail to positively identify the clinical suspicion of OM. Patients may derive relief from nonpharmacologic interventions and cholinesterase inhibitors, but most will desire better symptom control with corticosteroids or need other immunosuppression. Early corticosteroid therapy may reduce the probability of generalization of the disease. The reasons for ocular muscle involvement by OM include physiologic and cellular properties of the ocular motor system and the unique immunology of OM, which, when better understood, will lead to novel treatments. CONCLUSIONS OM is a challenging disorder for the clinician and scientist, with both learning from the other for the betterment of the patient. The future requires answers to why the ocular muscles are so frequently involved by MG, whether the generalization of the disease may be limited by early corticosteroid treatment, and what treatment options may be developed which will improve symptoms without long-term complications.
Collapse
Affiliation(s)
- Linda L Kusner
- Department of Neurology, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | | | | |
Collapse
|
50
|
Abstract
A variety of acute neurologic disorders present with visual signs and symptoms. In this review the authors focus on those disorders in which the clinical outcome is dependent on timely and accurate diagnosis. The first section deals with acute visual loss, specifically optic neuritis, ischemic optic neuropathy (ION), retinal artery occlusion, and homonymous hemianopia. The authors include a discussion of those clinical features that are helpful in distinguishing between inflammatory and ischemic optic nerve disease and between arteritic and nonarteritic ION. The second section concerns disc edema with an emphasis on the prevention of visual loss in patients with increased intracranial pressure. The third section deals with abnormal ocular motility, and includes orbital inflammatory disease, carotid-cavernous fistulas, painful ophthalmoplegia, conjugate gaze palsies, and neuromuscular junction disorders. The final section concerns pupillary abnormalities, with a particular emphasis on the dilated pupil and on carotid artery dissection. Throughout there are specific guidelines for the management of these disorders, and areas are highlighted in which there is ongoing controversy.
Collapse
Affiliation(s)
- Valerie Purvin
- Indiana University Medical Center, Department of Ophthalmology, Indianapolis, IN 46280, USA.
| | | |
Collapse
|