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Behbehani R. Ocular Myasthenia Gravis: A Current Overview. Eye Brain 2023; 15:1-13. [PMID: 36778719 PMCID: PMC9911903 DOI: 10.2147/eb.s389629] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/24/2023] [Indexed: 02/05/2023] Open
Abstract
Ocular myasthenia gravis (OMG) is a neuromuscular disease characterized by autoantibody production against post-synaptic proteins in the neuromuscular junction. The pathophysiological auto-immune mechanisms of myasthenia are diverse, and this is governed primarily by the type of autoantibody production. The diagnosis of OMG relies mainly on clinical assessment, the use of serological antibody assays for acetylcholine receptors (AchR), muscle-specific tyrosine kinase (MusK), and low-density lipoprotein 4 (LPR4). Other autoantibodies against post-synaptic proteins, such as cortactin and agrin, have been detected; however, their diagnostic value and pathogenic effect are not yet clearly defined. Clinical tests such as the ice test and electrophysiologic tests, particularly single-fiber electromyography, have a valuable role in diagnosis. The treatment of OMG is primarily through cholinesterase inhibitors (pyridostigmine), and steroids are frequently required in cases of ophthalmoplegia. Other immunosuppressive therapies include antimetabolites (azathioprine, mycophenolate mofetil, methotrexate) and biological agents such as B-cell depleting agents (Rituximab) and complement inhibitors (eculizumab). Evidence is scarce on the effect of immunosuppressive therapy on altering the natural course of OMG. Clinicians must be vigilant of a myasthenic syndrome in patients using immune-check inhibitors. Reliable and consistent biomarkers are required to assess disease severity and response to therapy to optimize the management of OMG. The purpose of this review is to summarize the current trends and the latest developments in diagnosing and treating OMG.
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Affiliation(s)
- Raed Behbehani
- Neuroophthalmology Unit, Ibn Sina Hospital, Kuwait City, Kuwait,Correspondence: Raed Behbehani, Ibn Sina Hospital, P.O Box 1180, Tel +965 2224 2999, Fax +965 2249 2406, Email
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Peng X, Xie XB, Tan H, Zhang D, Jiang BT, Liu J, Li S, Chen YR, Xie TY. Effects of Plasma Exchange Combined with Immunoglobulin Therapy on Consciousness, Immune Function, and Prognosis in Patients with Myasthenia Gravis Crisis: A Prospective Randomized Test. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:7796833. [PMID: 35813442 PMCID: PMC9262518 DOI: 10.1155/2022/7796833] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 05/30/2022] [Accepted: 06/09/2022] [Indexed: 12/02/2022]
Abstract
Background Myasthenia gravis (MG) is an acquired autoimmune disease. The main clinical features of MG are skeletal muscle fatigue and pathological fatigue, which worsen at night or after fatigue, such as dyspnea, dysphagia, and systemic weakness. Plasma exchange (PE) is often used in patients with acute exacerbation of MG. Intravenous immunoglobulin (IVIG) is a collection of immunoglobulins from thousands of donors. IVIG can replace a variety of immunosuppressants or PE. However, the effect of PE or IVIG on patients' consciousness, immune function, and prognosis is not clear. Objective A prospective randomized test of the effects of PE combined with immunoglobulin on consciousness, immune function, and prognosis in patients with myasthenia gravis crisis (MGC). Methods Sixty patients with MGC treated from February 2019 to April 2021 were enrolled in our hospital. The cases who received PE were set as the PE group, and those who received PE combined with immunoglobulin were set as the PE+immunoglobulin group. The efficacy, clinical score, state of consciousness, immune function, acetylcholine receptor antibody (AChR-Ab), lymphocyte (LYM), albumin (ALB) levels, and the incidence of adverse reactions were compared. Results The improvement rate was 100.005% in the treatment group and 83.33% in the PE group. After treatment, the clinical score of the PE+immunoglobulin group was lower than that of the PE group, and the clinical relative score of the PE+immunoglobulin group was higher than that of the PE group (P < 0.05). The number of conscious people in the PE+immunoglobulin group was more than that in the PE group (P < 0.05). Immunoglobulin A, immunoglobulin M, immunoglobulin G, and immunoglobulin G in the PE+immunoglobulin group were higher than those in the PE group (P < 0.05). The levels of AChR-Ab and ALB in the PE+immunoglobulin group were higher than those in the PE group, while the level of LYM in the PE+immunoglobulin group was lower than that in the PE group. The incidence of skin system, gastrointestinal system, nervous system, and systemic damage in the PE+immunoglobulin group was lower than that in the PE group (P < 0.05). Conclusion The treatment of MGC with PE combined with immunoglobulin can not only effectively enhance the consciousness and immune function of patients but also effectively promote the prognosis, and the safety of treatment can be guaranteed.
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Affiliation(s)
- Xu Peng
- Department of Neurology, The First Hospital of Changsha, Changsha, Hunan 410005, China
| | - Xiao-Bi Xie
- Department of Cardiology, The First Hospital of Changsha, Changsha, Hunan 410005, China
| | - Hong Tan
- Department of Neurology, The First Hospital of Changsha, Changsha, Hunan 410005, China
| | - Dan Zhang
- Department of Neurology, The First Hospital of Changsha, Changsha, Hunan 410005, China
| | - Bo-Tao Jiang
- Department of Neurology, The First Hospital of Changsha, Changsha, Hunan 410005, China
| | - Jie Liu
- Department of Neurology, The First Hospital of Changsha, Changsha, Hunan 410005, China
| | - Shuang Li
- Department of Neurology, The First Hospital of Changsha, Changsha, Hunan 410005, China
| | - Ya-Rui Chen
- Department of Neurology, The First Hospital of Changsha, Changsha, Hunan 410005, China
| | - Tao-Yang Xie
- Department of Neurology, The First Hospital of Changsha, Changsha, Hunan 410005, China
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Li H, Ruan Z, Gao F, Zhou H, Guo R, Sun C, Xu Q, Lu Q, Zhou Y, Zhao Z, Yu L, Wu S, Lei T, Gao T, Tang Y, Li C, Huo F, Zhu Y, Sun J, Tang B, Zhang M, Gao Y, Lu X, Li Z, Chang T. Thymectomy and Risk of Generalization in Patients with Ocular Myasthenia Gravis: A Multicenter Retrospective Cohort Study. Neurotherapeutics 2021; 18:2449-2457. [PMID: 34625864 PMCID: PMC8804035 DOI: 10.1007/s13311-021-01129-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 02/05/2023] Open
Abstract
This study aims to investigate the association between thymectomy and the risk of generalization in patients with ocular myasthenia gravis (MG). Data on patients with ocular MG from seven neurological centers in China were retrospectively reviewed. Ocular MG naïve to immunotherapy was categorized according to whether thymectomy was performed (thymectomized group vs. nonsurgical group). Patients in the thymectomized group all underwent surgery within 2 years since ocular symptom onset. The main outcome measure was the generalization. The follow-up period was defined from the date of ocular symptom onset to the date of generalization confirmation, immunotherapy initiation, or last follow-up (defined as 60 months). Of 519 eligible patients (mean [SD] age, 48.7 [15.2] years, 46.6% women), 31 (23.7%) of 131 generalized in the thymectomized group and 122 (31.4%) of 388 did in the nonsurgical group during a median follow-up of 19 months (IQR 8.0-50.0). Thymectomy was independently associated with reduced generalization risk (adjusted HR 0.41, 95% CI 0.25-0.66, P < 0.001). Multivariable stratified analysis also verified this association across the subgroups. Kaplan-Meier curves showed that the 5-year cumulative rate was significantly lower in the thymectomized group than in the nonsurgical group. To conclude, thymectomy may be considered effective in modifying the progression from ocular to generalized MG irrespective of thymoma.
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Affiliation(s)
- Huanhuan Li
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Zhe Ruan
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Feng Gao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Hongyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Rongjing Guo
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Chao Sun
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Quan Xu
- Department of Thoracic Surgery, Jiangxi Provincial People's Hospital Affiliated To Nanchang University, Nanchang, China
| | - Qiang Lu
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yongan Zhou
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Zhengwei Zhao
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, 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 Hospital, Xi'an, China
| | - Ting Gao
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Yonglan Tang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Chunhong Li
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Feiyan Huo
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Ying Zhu
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Jie Sun
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Baoli Tang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Min Zhang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Yanwu Gao
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Xiaodan Lu
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Zhuyi Li
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China.
| | - Ting Chang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China.
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Evoli A, Iorio R. Controversies in Ocular Myasthenia Gravis. Front Neurol 2020; 11:605902. [PMID: 33329368 PMCID: PMC7734350 DOI: 10.3389/fneur.2020.605902] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022] Open
Abstract
Myasthenia gravis (MG) with symptoms limited to eye muscles [ocular MG (OMG)] is a rare disease. OMG incidence varies according to ethnicity and age of onset. In recent years, both an increase in incidence rate, particularly in the elderly, and a lower risk for secondary generalization may have contributed to the growing disease prevalence in Western countries. OMG should be considered in patients with painless ptosis and extrinsic ophthalmoparesis. Though asymmetric muscle involvement and symptom fluctuations are typical, in some cases, OMG can mimic isolated cranial nerve paresis, internuclear ophthalmoplegia, and conjugate gaze palsy. Diagnostic confirmation can be challenging in patients negative for anti-acetylcholine receptor and anti-muscle-specific tyrosine kinase antibodies on standard radioimmunoassay. Early treatment is aimed at relieving symptoms and at preventing disease progression to generalized MG. Despite the absence of high-level evidence, there is general agreement on the efficacy of steroids at low to moderate dosage; immunosuppressants are considered when steroid high maintenance doses are required. The role of thymectomy in non-thymoma patients is controversial. Prolonged exposure to immunosuppressive therapy has a negative impact on the health-related quality of life in a proportion of these patients. OMG is currently excluded from most of the treatments recently developed in generalized MG.
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Affiliation(s)
- Amelia Evoli
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Raffaele Iorio
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
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Nguyen T, Phan CL, Supsupin E, Sheikh K. Therapeutic and Diagnostic Challenges in Myasthenia Gravis. Neurol Clin 2020; 38:577-590. [PMID: 32703470 DOI: 10.1016/j.ncl.2020.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
"Myasthenia gravis (MG) is the most common autoimmune neuromuscular disorder. This article highlights several cases that the practicing neurologist may encounter in the treatment of MG. Diagnostic uncertainty continues to be an issue in patients who are seronegative to the 2 most common antibodies, acetylcholine receptor and muscle-specific tyrosine kinase (MuSK). Specific populations of patients with MG including MuSK MG, thymomatous MG, refractory MG, and pregnant women also require special consideration. This article reviews specific cases and an update on current management."
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Affiliation(s)
- Thy Nguyen
- Department of Neurology, McGovern Medical School, University of Texas Houston Health Science Center, 6431 Fannin Street, MSE R 462, Houston, TX 77030, USA.
| | - Cecile L Phan
- 7-125 Clinical Sciences Building, 2J2.00 WC Mackenzie Health Sciences Centre, 8440 112 St. NW, Edmonton, Alberta, T6G 2R7 Canada
| | - Emilio Supsupin
- Department of Diagnostic and Interventional Imaging, 6431 Fannin St. 2.103 MSMB, Houston, Texas 77030, USA
| | - Kazim Sheikh
- Department of Neurology, McGovern Medical School, University of Texas Houston Health Science Center, 6431 Fannin street, MSE R454 Houston, TX 77030, USA
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