Myasthenia mimicking monocular elevation deficiency

Strabismus in chronic progressive external ophthalmoplegia

PURPOSE

To elucidate the patterns of strabismus and ophthalmoplegia associated with chronic progressive external ophthalmoplegia (CPEO) confirmed by mitochondrial DNA (mtDNA) deletions in Asians.

METHODS

A total of 10 patients confirmed to have mtDNA deletion associated with CPEO were included. Long-range PCR encompassing the entire mtDNA was carried out. In the cases with mtDNA deletion, the exact deletion ranges of mtDNA were identified by sequencing. A full ophthalmologic examination including prism and alternate cover test in the primary position, evaluation of ductions and versions, and binocularity was performed in 10 patients with confirmed mtDNA deletions associated with CPEO.

RESULTS

All of the patients showed ophthalmoplegia as well as ptosis, even after eyelid surgeries. Ophthalmoplegia was symmetric between both eyes in nine patients (90%) while one patient (10%) showed asymmetric ophthalmoplegia with esotropia and left hypotropia. Among the nine patients with symmetric involvement, four patients (44%) showed exotropia, three (33%) had exotropia with vertical deviation, and the remaining two patients (22%) showed orthotropia. Five out of 10 patients (50%) complained of diplopia associated with strabismus, four of whom (80%) had vertical deviation. Three out of five patients (60%) without diplopia showed exotropia of 20 prism diopters (PD) to 50 PD.

CONCLUSIONS

Exotropia with/without vertical deviation is the most common form of strabismus in Asian patients with CPEO and only one of them showed a small angle of esotropia. Ophthalmoplegia could be asymmetric in 10% of CPEO patients.

Diagnostic value of repeated ice tests in the evaluation of ptosis in myasthenia gravis

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).

CHARGE syndrome with oculomotor nerve palsy

CHARGE syndrome is a congenital disorder characterized by coloboma, heart defects, atresia of the choanae, retarded growth, genital hypoplasia, ear anomalies, and/or hearing loss. We report the case of a 2-year-old boy with CHARGE syndrome who presented with left exotropia and elevation deficit since infancy. He had patent ductus arteriosus, small testicles, growth retardation, auricular deformity, left semicircular canal aplasia, and a de novo nonsense mutation (p.Ser705X) of the CHD7 gene. He had a left exotropia of 40 prism diopters, marked limitation of upgaze and mild limitation of downgaze and adduction in the left eye. On upgaze, his left eye adducted but did not elevate. The pupils of both eyes were round and isocoric. Fundus examination revealed optic disk and choroidal colobomas. CHARGE syndrome with oculomotor nerve palsy has not been reported previously.