Ocular myasthenia gravis - How effective is low dose prednisone long term?

A Male Patient Presents With Isolated Abducens Nerve Palsy: An Atypical Presentation of Ocular Myasthenia Gravis

Myasthenia gravis is an autoimmune disease of the neuromuscular junction caused by autoantibodies directed against the acetylcholine receptors. It presents with skeletal muscle weakness, often initially presenting with ocular symptoms such as ptosis and diplopia. When myasthenia gravis is isolated to only ocular symptoms, it is referred to as ocular myasthenia gravis (OMG). Here, we present an atypical initial presentation of OMG in a 68-year-old male patient presenting with isolated abducens nerve palsy at the initial onset. With this case report, we highlight the importance of a thorough history and clinical assessment necessary for a timely diagnosis of OMG in patients who present with isolated abducens nerve palsy.

A controlled clinical study on efficacy and safety of periocular triamcinolone acetonide injection for treating ocular myasthenia gravis

OBJECTIVE

To evaluate the efficacy and safety of peribulbar triamcinolone acetonide injection for treating ocular myasthenia gravis (OMG), with a comparison of traditional oral drug therapy.

METHODS

A total of 22 patients with OMG who received periocular triamcinolone acetonide injection (initially 20 mg weekly, then once per month later if symptoms were improved) from July 2019 to July 2022 were evaluated by a comparison of symptom degree before and after treatment. Adverse reactions were also monitored during the period of treatment. The period of follow-up was more than 6 months. Additionally, a comparison of the treatment efficacy between this periocular injection and traditional oral administration was performed in OMG patients.

RESULTS

After 4 weeks of treatment, the degree of ptosis in OMG patients decreased to -3.00 ± 0.69, compared to the value (-0.86 ± 1.32) before treatment. The degree of ophthalmoplegia also decreased from 3.12 ± 0.72 to 0.86 ± 0.88 (P < 0.001) after treatment. The achievement rates of minimal manifestations status (MMS)for ptosis and ophthalmoplegia after 4 week-treatment were 86.3% and 75%, respectively, while they were 50% and 30% in patients with traditional oral administration. There was statistically significant difference only in MMS (rather than symptom relief rate and generalization conversion rate) between two groups. No serious complications (except for intraorbital hematoma) were found in OMG patients during the treatment period.

CONCLUSION

Repeated peribulbar injection of triamcinolone acetonide can effectively alleviate the initial symptoms of OMG patients. However, the evaluation of its long-term efficacy is still needed.

CLINICAL TRIAL REGISTRY

This study has been clinically registered by Chinese Clinical Trial Registry (ChiCTR), first trial registration date:05/07/2019, registration number: ChiCTR1900024285.

Comparative effectiveness and safety of intravenous methylprednisolone and tacrolimus monotherapy in ocular myasthenia gravis with unsatisfactory prednisone responses: a retrospective study

BACKGROUND

Oral prednisone has been recognized as the first-line therapy for the treatment of ocular myasthenia gravis (OMG). However, its long-term use is complicated by numerous adverse effects and is ineffective for some OMG patients in reaching remission. This study aimed to evaluate the effectiveness and safety of intravenous methylprednisolone (IVMP) and tacrolimus monotherapy for OMG patients with unsatisfactory responses to conventional prednisone therapy.

METHODS

We retrospectively reviewed 57 OMG patients who had not achieved satisfactory improvement after prednisone therapy and thereby received IVMP or tacrolimus monotherapy for at least 6 months. Ocular symptoms were evaluated by the ocular-quantitative MG (QMG) score at each time point. A ≥ 2-point fall in ocular QMG score was defined as the cut-off point to indicate clinical improvement. Logistic regression analysis was performed to identify factors associated with the efficacy of IVMP at discharge. Adverse events were recorded.

RESULTS

Both IVMP and tacrolimus monotherapy demonstrated significant clinical efficacy, with no statistical differences observed at the study endpoint. The proportions of patients who reached the cut-off point for efficacy evaluation were higher in the IVMP group than in the tacrolimus group (1, 3, and 6 months: 51.7% (15/29) vs 12.0% (3/25), p = 0.002; 69.0% (20/29) vs 40.0% (10/25), p = 0.033; 69.0% (20/29) vs 46.4% (13/28), p = 0.085, respectively). Multivariate logistics analysis showed that high ocular QMG scores at baseline indicated favourable responses to IVMP treatment (OR = 1.781; 95% CI 1.066-2.975; p = 0.028). All the adverse events were transient and tolerable.

CONCLUSION

Our findings suggest that both IVMP and tacrolimus monotherapy hold promise as viable treatment options for OMG patients with unsatisfactory responses to oral prednisone. The study supports the safety and effectiveness of both therapies, with IVMP exhibiting faster improvement and favourable efficacy in patients with high ocular QMG scores.

Prognostic predictors of remission in ocular myasthenia gravis

BACKGROUND

Ocular myasthenia gravis (OMG) constitutes 15% of all myasthenia gravis patients.

METHODS

One hundred eight patients with OMG followed-up for over 36 months were retrospectively evaluated regarding factors associated with remission. Demographic features, neuro-ophthalmologic findings at onset, acetylcholine receptor (AChR Ab) and muscle-specifc tyrosine kinase antibodies (MuSK Ab), thymic status, single fiber electromyography (SFEMG) results were the variables considered.

RESULTS

Median age of disease onset was 57 years (range 18-82 years). Clinical features at onset was isolated ptosis in 55 (50.9%) and isolated diplopia in 33 (30.6%) patients. Combined ptosis and diplopia were present in 20 (18.5%) patients. Among 75 patients with ptosis, it was unilateral in 65 (86.7%) and bilateral in 10 (13.3%). AChR Abs were found in 66 (61.1%) and MuSK Abs in 2 (1.9%) patients. SFEMG abnormality was detected in 74 (68.5%) patients. Thymoma was present in 16 (14.8%) and thymic hyperplasia in 6 (5.6%) patients. Forty-one patients (37.9%) had been treated with pyridostigmine alone. Sixty-seven (62%) patients were given immunosupressive drugs. In 53 (49.1%) prednisone was used and in 14 (12.9%) patients it was combined with azathioprine. Thymectomy was performed in all 16 patients with thymoma. Complete stable remission (CSR) was achieved in 49 (45.4%) patients. Fifty-nine (54.6%) patients had reached minimal manifestation (MM) status; 32 (29.6%) having a status of MM-1 and 27 (25%) a status of MM-3.

CONCLUSIONS

The presence of AchR Abs (p = 0.034) and an abnormal SFEMG (p = 0.006) at onset as increased risk factors for the presence of ongoing signs necessitating medical treatment.

Dynamic nomogram for predicting generalized conversion in adult-onset ocular myasthenia gravis

PURPOSE

To explore the factors and risk mapping model of progression from ocular myasthenia gravis (OMG) to generalized myasthenia gravis (GMG) in adult-onset patients.

METHODS

A retrospective, observational cohort study was performed for 435 OMG patients with onset age older than 14 years old. Multivariate Cox regression was used to identify the independent factors affecting generalized conversions that then were incorporated into the construction of the nomogram.

RESULTS

Two hundred thirty-seven patients (54.5%) had transformed into GMG after a median of 1.1 years (range 0.1--9.1 years). The 6-, 12-, and 24-month generalized conversion rates were 31.7%, 49.8%, and 65.4%, respectively. Multivariable analysis showed that the early-onset age, male sex, concomitant autoimmune diseases (AID), positive results of anti-acetylcholine receptor antibodies, repetitive nerve stimulation abnormalities, the presence of thymoma, and prednisone treatment were significantly associated with the generalized conversions (hazard ratio [HR] = 0.598, 0.686, 1.554, 1.541, 2.020, 2.510, and 0.556, respectively). A nomogram was established to predict the possibility of generalization-free survival (GFS) in adult-onset OMG patients, and the model demonstrated good predictive performance with a C-index of 0.736 (95% confidence interval 0.703 ~ 0.769). Moreover, subgroup analyses were performed based on the presence or absence of prednisone therapy, and the results indicated that prednisone therapy has better prevention of generalized conversions in male, non-thymoma patients, and patients without other AID.

CONCLUSION

A new predictive nomograph and web-based survival calculator we developed show favorable applicability and accuracy in predicting long-term GFS in adult-onset OMG patients.

Immunotherapy for ocular myasthenia gravis: an observational study in Japan

Background

Treatment for ocular myasthenia gravis (OMG) has not yet been well established. Few reports have been published on the clinical practice and outcomes of OMG.

Objectives

We investigated treatment of OMG and its outcomes in Japan.We investigated treatment of OMG and its outcomes in Japan.

Design

We performed a retrospective cross-sectional survey of OMG patients from eight hospitals in Japan.

Methods

Clinical information, including sex, age at onset, initial symptoms, autoantibodies, clinical course, treatment history, complications, and outcomes, was obtained. In addition, we recorded the total number of patients with MG and OMG separately.

Results

In total, 135 patients with OMG (67 men, 68 women) were included. Treatment of OMG was not simple and involved various immunotherapeutic strategies. Eight patients went into remission spontaneously without immunotherapy. A total of 117 patients showed improvements after treatment, whereas 10 patients showed refractory responses to treatment. Overall outcomes were good; however, symptoms persisted in 60.7% of patients even after treatment. Among 90 patients who received immunotherapy, only two showed a refractory response. Meanwhile, for 45 patients who did not receive immunotherapy, 8 were refractory. Thus, the rate of refractory disease in the group with immunotherapy was significantly lower (p = 0.001, u-test) than in the group without immunotherapy. The proportion of generalized MG patients among all MG cases was low in medical centers where immunotherapy for OMG was frequently performed.

Conclusion

Although the overall prognosis for patients with OMG was good, symptoms remained in more than half of the patients. Immunotherapy, including corticosteroids, may be beneficial for patients with OMG.

Plain language summary

Is immunosuppressive therapy beneficial for myasthenia gravis patients with ocular symptoms only? Patients with ocular myasthenia gravis (OMG) have only eye symptoms for more than 2 years. Whether this condition is an initial stage of the disease before eventually progressing to generalized myasthenia gravis (gMG) is still uncertain. Different from gMG, OMG is not life-threatening. But eye symptoms often cause troublesome problems in life. Doctors have treated OMG patients similarly to patients with gMG. There is no standard clinical practice for OMG. In this study, we examined how patients with OMG were treated at eight different specialist centers in Japan. In 135 patients with OMG, 8 patients became symptom free without treatment, 117 patients showed improvements after treatment, whereas 10 patients did not get well. Overall outcomes were good, but symptoms remained in 60.7% of patients even after treatment. Among 90 patients who received one or more immunotherapies, only 2 did not get well. Meanwhile, for 45 patients who did not receive immunotherapy, 8 remained ill. We found that treatment of OMG was not simple and often needed multiple immunotherapies. Administering immunotherapy, including corticosteroids, may be beneficial for patients with OMG.

Clinical Efficacy of Immunoglobulin Combined with Glucocorticoids in the Treatment of Oculomotor Myasthenia Gravis in Children and the Effect on Serum Immunity

To investigate the effects of treatment with immunoglobulin on clinical outcomes and immune function in children with oculomotor myasthenia gravis. The clinical data of 100 pediatric patients with oculomotor myasthenia gravis treated in our hospital from January 2019 to December 2021 were selected as the subjects of this retrospective study and divided into a comparison group and a treatment group according to the different treatment methods. The comparison group was treated with glucocorticoids, and the treatment group was treated with immunoglobulin on the basis of the comparison group. The differences in the serum indexes, the effects of immune function, and the clinical efficacy of the two groups were observed and compared. It was found the comparison of immunoglobulin G (IgG), immunoglobulin A (IgA), and immunoglobulin M (IgM) after treatment was significantly different and lower in the treatment group than in the comparison group; the comparison of CD4+, CD3+, CD4+/CD8+, and NK cells after treatment was significantly different and higher in the treatment group than in the comparison group. The effective rate of 98.00% in the treatment group was significantly higher than that of 76.00% in the comparison group, and the difference was statistically significant. The clinical efficacy of the two groups showed that the fever, cough, sputum, myasthenia gravis crisis, and gastrointestinal reactions in the treatment group were significantly lower than those in the comparison group. The study indicates that comparative study of children with oculomotor myasthenia gravis treated with immunoglobulin combined with glucocorticoids is more effective, effectively improving the immune level of patients and reducing adverse reactions.

Prediction of the generalization of myasthenia gravis with purely ocular symptoms at onset: a multivariable model development and validation

Background

About half of myasthenia gravis (MG) patients with purely ocular symptoms at onset progress to generalized myasthenia gravis (gMG).

Objectives

To develop and validate a model to predict the generalization of MG at 6 months after disease onset in patients with ocular-onset myasthenia gravis (OoMG).

Methods

Data of patients with OoMG were retrospectively collected from two tertiary hospitals in Germany and China. An accelerated failure time model was developed using the backward elimination method based on the German cohort to predict the generalization of OoMG. The model was then externally validated in the Chinese cohort, and its performance was assessed using Harrell's C-index and calibration plots.

Results

Four hundred and seventy-seven patients (275 from Germany and 202 from China) were eligible for inclusion. One hundred and three (37.5%) patients in the German cohort progressed from OoMG to gMG with a median follow-up time of 69 (32-116) months. The median time to generalization was 29 (16-71) months. The estimated cumulative probability of generalization was 30.5% [95% CI (confidence interval), 24.3-36.2%) at 5 years after disease onset. The final model, which was represented as a nomogram, included five clinical variables: sex, titer of anti-AChR antibody, status of anti-MuSK antibody, age at disease onset and the presence of other autoimmune disease. External validation of the model using the bootstrap showed a C-index of 0.670 (95% CI, 0.602-0.738). Calibration curves revealed moderate agreement of predicted and observed outcomes.

Conclusion

The nomogram is a good predictor for generalization in patients with OoMG that can be used to inform of the individual generalization risk, which might improve the clinical decision-making.

Current Treatment of Myasthenia Gravis

Myasthenia gravis (MG) is the most extensively studied antibody-mediated disease in humans. Substantial progress has been made in the treatment of MG in the last century, resulting in a change of its natural course from a disease with poor prognosis with a high mortality rate in the early 20th century to a treatable condition with a large proportion of patients attaining very good disease control. This review summarizes the current treatment options for MG, including non-immunosuppressive and immunosuppressive treatments, as well as thymectomy and targeted immunomodulatory drugs.

Association of immunosuppression treatment with generalization among patients with ocular myasthenia gravis: a propensity score analysis

BACKGROUND

To analyze disease generalization in patients with ocular myasthenia gravis (OMG) treated with immunosuppression compared with patients without immunosuppression treatment.

METHODS

In this retrospective cohort study, we analyzed data from patients with OMG at seven medical centers in China from January 1, 2015 to May 1, 2019 and compared disease generalization in patients (treated with immunosuppression vs. not treated) within 2 years of disease onset using raw and inverse probability of treatment weighting (IPTW) analyses.

RESULTS

In the study population of 813 patients with OMG, 425 (52.3%) with immunosuppression had a mean (SD) onset age of 50.0 (15.1) years, and 188 (44.2%) were women. The remaining 388 (47.7%) patients were not immunosuppressed (mean age, 48.4 [15.0] years; 185 [47.7%] women). Disease generalization developed in 122 (31.4%) and 37 (8.7%) patients in the non-immunosuppression and immunosuppression groups, respectively. Relative to non-immunosuppression, immunosuppression was associated with a lower risk of generalization in a multivariable-adjusted Cox model (hazard ratio [HR], 0.27; 95% confidence interval [CI], 0.18-0.40; P<0.001) and IPTW-weighted Cox model (HR, 0.28; 95% CI, 0.19-0.42; P<0.001). In sensitivity analyses, longer duration of immunosuppression was associated with a lower risk of generalization (HR, 0.90 for every one-month increase; 95% CI, 0.87-0.92; P<0.001; IPTW-adjusted). Combination therapy with steroids and non-steroidal immunosuppressants showed superior efficacy in reducing the risk of generalization (HR, 0.14; 95% CI, 0.07-0.26; P<0.001).

CONCLUSIONS

Immunosuppression significantly reduced the 2-year risk of generalization in patients with OMG.

JNO Literature Commentary

June 2021' In this issue of JNO, Drs. M. Tariq Bhatti and Mark L. Moster discuss the following 6 articles: Vynckier J, Demeestere J, Lambert J. Black-blood MRI in Giant Cell Arteritis. J Rheumatol. 2021;48:301-302.Hwang CJ, Nichols EE, Chon BH, Perry JD. Bilateral dysthyroid compressive optic neuropathy responsive to teprotumumab. Eur J Ophthalmol. 2021:1120672121991042. doi: 10.1177/1120672121991042. Epub ahead of print. PMID: 33525898.Narayanaswami P, Sanders DB, Wolfe G, Benatar M, Cea G, Evoli A, Gilhus NE, Illa I, Kuntz NL, Massey J, Melms A, Murai H, Nicolle M, Palace J, Richman D, Verschuuren J. International Consensus Guidance for Management of Myasthenia Gravis: 2020 Update. Neurology. 2021;96:114-122.Mastrangelo V, Merli E, Rucker JC, Eggenberger ER, Zee DS, Cortelli P. Neuro-Ophthalmological Findings in Early Fatal Familial Insomnia. Ann Neurol. 2021. doi: 10.1002/ana.26008. Epub ahead of print. PMID: 33386648.D'Antona L, Jaime Merchan MA, Vassiliou A, et al. Clinical Presentation, Investigation Findings, and Treatment Outcomes of Spontaneous Intracranial Hypotension Syndrome: A Systematic Review and Meta-analysis. JAMA Neurol. Published online January 04, 2021. doi:10.1001/jamaneurol.2020.4799.Simonett JM, Skalet AH, Lujan BJ, Neuwelt EA, Ambady P, Lin P. Risk Factors and Disease Course for Blood-Brain Barrier Disruption-Associated Maculopathy. JAMA Ophthalmol. 2021;139:143-149. doi: 10.1001/jamaophthalmol.2020.5329. PMID: 33270081; PMCID: PMC7716256.