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Donaldson L, Issa M, Dezard V, Margolin E. Low probability of myasthenia Gravis in patients presenting to neuro-ophthalmology clinic for evaluation of isolated ptosis. Eur J Ophthalmol 2023; 33:524-529. [PMID: 35686323 PMCID: PMC9834322 DOI: 10.1177/11206721221107300] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Concerning causes of ptosis, most notably third nerve palsy and Horner's syndrome, can be ruled out with normal ocular motility and pupillary examination. Myasthenia gravis (MG) however, rarely can present with ptosis as an isolated finding. We reviewed all patients presenting to tertiary neuro-ophthalmology practice with ptosis of unknown etiology to determine the frequency of MG. METHODS Retrospective chart review of patients referred to a tertiary neuro-ophthalmology practice with undifferentiated ptosis. RESULTS Sixty patients were included in the study. Twenty eight (47%) patients had ptosis along with various abnormalities of ocular motility and/or alignment and 32 (53%) had isolated unilateral ptosis defined as ptosis with absence of diplopia, or symptoms of generalized MG (GMG). Final diagnosis was aponeurotic ptosis due to levator palpebrae dehiscence in the majority (73%) of patients, while 10 (17%) were diagnosed with MG (6 with OMG, 4 with GMG). Diplopia was present in 9/10 patients with MG and 8/10 had abnormal ocular findings on clinical examination such as orbicularis oculi weakness, Cogan's lid twitch or fatiguability of ptosis on sustained upgaze. Only one patient referred for isolated unilateral ptosis was diagnosed with OMG and this patient had orbicularis oculi weakness. CONCLUSIONS None of the patients with isolated unilateral ptosis and otherwise normal examination had MG. All patients eventually diagnosed with MG had diplopia or orbicularis weakness on examination. Thus, the yield of investigating patients with isolated ptosis for MG is exceedingly low.
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Affiliation(s)
- Laura Donaldson
- Department of Surgery, Division of Ophthalmology, McMaster University, Hamilton, Ontario, Canada
| | - Mariam Issa
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Victoria Dezard
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Edward Margolin
- Department of Ophthalmology and Vision Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada,Department of Medicine, Division of Neurology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada,Edward Margolin, University of Toronto, Faculty of Medicine, Department of Ophthalmology and Medicine (Neurology), 801 Eglinton Ave West Suite 301, Toronto ON M5N 1E3.
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Glover K, Mishra D, Singh TRR. Epidemiology of Ocular Manifestations in Autoimmune Disease. Front Immunol 2021; 12:744396. [PMID: 34795665 PMCID: PMC8593335 DOI: 10.3389/fimmu.2021.744396] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/14/2021] [Indexed: 01/19/2023] Open
Abstract
The global prevalence of autoimmune diseases is increasing. As a result, ocular complications, ranging from minor symptoms to sight-threatening scenarios, associated with autoimmune diseases have also risen. These ocular manifestations can result from the disease itself or treatments used to combat the primary autoimmune disease. This review provides detailed insights into the epidemiological factors affecting the increasing prevalence of ocular complications associated with several autoimmune disorders.
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Affiliation(s)
| | | | - Thakur Raghu Raj Singh
- School of Pharmacy, Medical Biology Centre, Queen’s University Belfast, Belfast, United Kingdom
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Myasthenia Gravis-An Analysis of Multimodal Evoked Potentials. Brain Sci 2021; 11:brainsci11081057. [PMID: 34439676 PMCID: PMC8392656 DOI: 10.3390/brainsci11081057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The aim of this study is a comprehensive analysis of the parameters of exogenous evoked potentials (visual, brainstem auditory, and somatosensory) in patients with myasthenia gravis (MG), a prototype of both neuromuscular junction disease and autoimmune disease. The study also seeks to isolate electrophysiological changes that may indicate disorders within the central and/or peripheral nervous system. METHODS A total of forty-two consecutive patients with myasthenia gravis (24 women, 18 men) were included in the study. All of the patients underwent EP examination. MR images were also analyzed. RESULTS In the group of MG patients, the latency of P100 (113.9 ± 13.9; p < 0.0001) VEP, wave III (3.92 ± 0.29; p = 0.015), wave V (5.93 ± 0.32; <0.0001), interlatency III-V (2.00 ± 0.12; p < 0.0001), interlatency I-V (4.20 ± 0.28; p < 0.001) BAEP, and all components of SEP (N9, P10, N13, P16, N20, P22) were significantly longer. Mean wave I and V amplitude BAEP were relatively lower. CONCLUSIONS The results of the study suggest the presence of disturbances in the bioelectric activities of the central and peripheral nervous system in MG patients.
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Uribe-Reina P, Muñoz-Ortiz J, Cifuentes-González C, Reyes-Guanes J, Terreros-Dorado JP, Zambrano-Romero W, López-Rojas C, Mantilla-Sylvain F, Mantilla-Hernández RD, de-la-Torre A. Ocular Manifestations in Colombian Patients with Systemic Rheumatologic Diseases. Clin Ophthalmol 2021; 15:2787-2802. [PMID: 34234401 PMCID: PMC8254180 DOI: 10.2147/opth.s306621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 04/20/2021] [Indexed: 12/18/2022] Open
Abstract
PURPOSE To establish the prevalence of ocular involvement in a Colombian population with rheumatologic diseases. DESIGN Observational cross-sectional study. METHODS We included a probabilistic sample size of 797 patients who attended a rheumatologic disease center in Bogotá, Colombia. Statistical analysis with descriptive measures and Chi-square independence test between rheumatologic diseases and ophthalmological symptoms and diseases was performed. RESULTS Eighty-four percent of the population were women, and the mean age was 54.61± 15.64 years. The most common condition was rheumatoid arthritis (33.37%), followed by fibromyalgia (22.71%), Sjögren Syndrome (19.72%), and systemic lupus erythematosus (9.91%). Almost 7% of the patients presented polyautoimmunity. Thirty-five percent of the patients reported one or more ophthalmological symptoms, being dry eye sensation the most common (30.86%), followed by ocular pain (2.76%), red-eye, and decreased visual acuity (both 2.63%). Similarly, 21.45% of the patients presented one or more ophthalmological diagnoses, being keratoconjunctivitis sicca the most common (15.93%), followed by cataract, uveitis (1.38% each), and scleritis (1.25%). CONCLUSION Almost a third of the patients reported any ocular involvement. It is crucial to be aware of the most common ophthalmic manifestations among the different rheumatologic diseases in our population, to offer early specialist referral and timely treatment.
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Affiliation(s)
- Pilar Uribe-Reina
- Neuroscience Research Group “NeURos”, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
- Escuela Barraquer, Research Group, Escuela Superior de Oftalmología del Instituto Barraquer de América, Bogotá, Colombia
| | - Juliana Muñoz-Ortiz
- Neuroscience Research Group “NeURos”, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
- Escuela Barraquer, Research Group, Escuela Superior de Oftalmología del Instituto Barraquer de América, Bogotá, Colombia
| | - Carlos Cifuentes-González
- Neuroscience Research Group “NeURos”, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Juliana Reyes-Guanes
- Escuela Barraquer, Research Group, Escuela Superior de Oftalmología del Instituto Barraquer de América, Bogotá, Colombia
| | - Juan Pablo Terreros-Dorado
- Neuroscience Research Group “NeURos”, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - William Zambrano-Romero
- Neuroscience Research Group “NeURos”, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
- Fundación Para la Investigación en Dermatología y Reumatología (FUNINDERMA), Bogotá, Colombia
| | - Carolina López-Rojas
- Escuela Barraquer, Research Group, Escuela Superior de Oftalmología del Instituto Barraquer de América, Bogotá, Colombia
| | - Fabien Mantilla-Sylvain
- Fundación Para la Investigación en Dermatología y Reumatología (FUNINDERMA), Bogotá, Colombia
| | | | - Alejandra de-la-Torre
- Neuroscience Research Group “NeURos”, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
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Fisher KS, Gill J, Todd HF, Yang MB, Lopez MA, Abid F, Lotze T, Shah VS. Pediatric Autoimmune Ocular Myasthenia Gravis: Evaluation of Presentation and Treatment Outcomes in a Large Cohort. Pediatr Neurol 2021; 118:12-19. [PMID: 33684630 DOI: 10.1016/j.pediatrneurol.2021.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND In autoimmune myasthenia gravis (MG), autoantibodies target the neuromuscular junction. Ocular myasthenia gravis (OMG) is localized, affecting only extraocular and/or levator palpebrae muscles. OMG presents across all ages, varying in presentation, treatment modalities, and outcomes. Recently, there have been advances in MG/OMG treatment; their utilization and effectiveness are an important part of optimal disease management. METHODS We completed a retrospective chart review of children aged 18 years or younger with a confirmed diagnosis of OMG presenting from 2002 to 2019. RESULTS Forty-two patients were included with mean age at presentation of 8.5 years (2 to 18 years). Twenty-one patients (50%) had positive antibodies; 90% had acetylcholine receptor antibodies. Ten patients developed generalized symptoms with mean time to generalization of 13.6 months. Multiple logistic regression showed that older age of onset was a trend predictive factor (P = 0.054; odds ratio 1.17) for generalized disease. All patients were treated with pyridostigmine. Immunomodulating agents included steroids (15), mycophenolate mofetil (four), and intravenous immunoglobulin (one). Three patients underwent thymectomy. Twenty patients reached minimal manifestation status, and 12 achieved remission. Gender, race, and positive antibody status were not statistically significant predictors for advanced immunosuppressive therapy. CONCLUSIONS We summarize one of the largest cohorts of pediatric patients with OMG who have undergone up-to-date diagnostic and therapeutic regimens. The predictors of outcome and treatment pathway for OMG patients suggested by this report may be further elucidated by future prospective studies.
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Affiliation(s)
- Kristen S Fisher
- Department of Pediatric Neurology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Jason Gill
- Department of Pediatric Neurology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | | | - Michael B Yang
- Division of Pediatric Ophthalmology, Abrahamson Pediatric Eye Institute, Cincinnati, Ohio; Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael A Lopez
- Hess Pediatric Ophthalmology Specialist, St. Petersburg, Florida
| | - Farida Abid
- Department of Pediatric Neurology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Timothy Lotze
- Department of Pediatric Neurology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Veeral S Shah
- Division of Pediatric Ophthalmology, Abrahamson Pediatric Eye Institute, Cincinnati, Ohio; Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Arnon R, Yahalomi T, Rozen-Knisbacher I, Pikkel J, Mostovoy D. Ocular Myasthenia Gravis with Severe Blepharitis and Ocular Surface Disease: A Case Report. Case Rep Ophthalmol 2020; 11:322-329. [PMID: 32884545 PMCID: PMC7443649 DOI: 10.1159/000508815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/20/2020] [Indexed: 11/19/2022] Open
Abstract
Ocular myasthenia gravis (OMG) is an autoimmune disease of the neuromuscular junction and commonly associated with other immune diseases. We describe a 16-year-old female who presented to our clinic with 1-month complaints of diplopia and strabismus, visual acuity deterioration, and ocular irritation. Her examination showed crossed diplopia and alternating exotropia of 25 prism diopters, severe blepharitis, conjunctival hyperemia, corneal pannus, epithelial irregularities, and subepithelial opacities. Workup included pediatric neurologic examination, laboratory tests, imaging, and electrophysiological tests. Diagnoses of OMG and blepharitis with ocular surface disease were made. Topical treatment included eyelid hygiene, tea tree oil scrubbing, topical steroids, and tacrolimus ointment. Systemic treatment included corticosteroids, pyridostigmine, azathioprine, intravenous immunoglobulins, amitriptyline, and doxycycline. Both diseases were refractory to intensive immunosuppressive treatment and had simultaneous relapses and an intertwined course. Our hypothesis is that a shared immune mechanism may be the cause of both OMG and ocular surface disease in our patient.
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Affiliation(s)
- Roee Arnon
- Department of Ophthalmology, Assuta-Samson Medical Center, Ashdod, Israel
| | - Tal Yahalomi
- Department of Ophthalmology, Assuta-Samson Medical Center, Ashdod, Israel
| | - Irit Rozen-Knisbacher
- Department of Ophthalmology, Assuta-Samson Medical Center, Ashdod, Israel.,Ben Gurion University School of Medicine, Beer-Sheva, Israel
| | - Joseph Pikkel
- Department of Ophthalmology, Assuta-Samson Medical Center, Ashdod, Israel.,Ben Gurion University School of Medicine, Beer-Sheva, Israel
| | - Dina Mostovoy
- Department of Ophthalmology, Assuta-Samson Medical Center, Ashdod, Israel.,Ben Gurion University School of Medicine, Beer-Sheva, Israel
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Maintenance immunosuppression in myasthenia gravis, an update. J Neurol Sci 2019; 410:116648. [PMID: 31901719 DOI: 10.1016/j.jns.2019.116648] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/25/2019] [Accepted: 12/24/2019] [Indexed: 01/08/2023]
Abstract
Therapies for myasthenia gravis (MG) include symptomatic and immunosuppressive/immunomodulatory treatment. Options for immunosuppression include corticosteroids, azathioprine, mycophenolate mofetil, cyclosporine, tacrolimus, methotrexate, rituximab, cyclophosphamide, eculizumab, intravenous immunoglobulin, subcutaneous immunoglobulin, plasmapheresis, and thymectomy. The practical aspects of long-term immunosuppressive therapy in MG are critically reviewed in this article. Application of one or more of these specific therapies is guided based on known efficacy, adverse effect profile, particular disease subtype and severity, and patient co-morbidities.
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Abstract
Myasthenia gravis (MG) is an autoimmune disease involving the neuromuscular junction. Autoantibodies to the acetylcholine receptor or, less frequently, to muscle-specific kinase, attack against the postsynaptic junctional proteins, resulting in fluctuating and variable weakness of muscles. Extraocular, levator palpebrae superioris, and orbicularis oculi muscles are particularly susceptible. The majority of patients with MG present with purely ocular symptoms including ptosis and diplopia initially. About half of these patients progress to generalized disease within 2 years. The prevalence of MG in Taiwan is 140 per million with male to female ratio of 0.7. The incidence rate is higher in the elderly. Several immune-related diseases such as lymphoid malignancy, diabetes, and thyroid diseases are associated with MG in the national population-based studies in Taiwan. Ice pack test, rest test, Tensilon/neostigmine test, circulating antibody measurement, and electrophysiological studies are useful diagnostic tools with variable sensitivity and specificity. For the patients with ocular MG, acetylcholinesterase inhibitors are usually the first-line treatment. Corticosteroids and immunosuppressant could provide better disease control and may reduce the risk of conversion to generalized form although there is still some controversy. A thymectomy is also beneficial for ocular MG, especially in refractory cases. The correction of ptosis and strabismus surgery could improve the visual outcome but should be performed only in stable disease.
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Affiliation(s)
- Chao-Wen Lin
- National Taiwan University Hospital, Taipei City, Taiwan
| | - Ta-Ching Chen
- National Taiwan University Hospital, Taipei City, Taiwan
| | - Jieh-Ren Jou
- National Taiwan University Hospital, Taipei City, Taiwan.,Changhua Christian Hospital, Changhua, Taiwan
| | - Lin-Chung Woung
- National Taiwan University Hospital, Taipei City, Taiwan.,Taipei City Hospital, Taipei City, Taiwan
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Maintenance immunosuppression in myasthenia gravis. J Neurol Sci 2016; 369:294-302. [DOI: 10.1016/j.jns.2016.08.057] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/20/2016] [Accepted: 08/26/2016] [Indexed: 11/17/2022]
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Patil SA, Bokoliya SC, Nagappa M, Taly AB. Diagnosis of myasthenia gravis: Comparison of anti-nicotinic acetyl choline receptor antibodies, repetitive nerve stimulation and Neostigmine tests at a tertiary neuro care centre in India, a ten year study. J Neuroimmunol 2016; 292:81-4. [PMID: 26943963 DOI: 10.1016/j.jneuroim.2016.01.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 11/21/2015] [Accepted: 01/06/2016] [Indexed: 12/01/2022]
Abstract
Anti-nicotinic AChR antibodies (Anti-nAChR antibodies), Repetitive Nerve Stimulation (RNS) and Neostigmine test are used for diagnosis of myasthenia gravis (MG). We compared their diagnostic agreement in a cohort of 486 MG patients over a period of ten years. Anti-nAChR antibodies, RNS and Neostigmine test showed positivity of 57.36%, 51.78%, and 93.4% respectively in ocular myasthenia and 93.77%, 82.35%, and 97.92% respectively in generalized myasthenia group. Neostigmine test showed higher positivity than anti-nAChR antibodies and RNS test in both groups. A marginal to fair agreement was observed between these tests highlighting their significance in the diagnosis of the disease.
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Affiliation(s)
- Shripad A Patil
- Department of Neuromicrobiology, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore 560029, India.
| | - Suresh C Bokoliya
- Department of Neuromicrobiology, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore 560029, India
| | - Madhu Nagappa
- Department of Neurology, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore 560029, India
| | - Arun B Taly
- Department of Neurology, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore 560029, India
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Litwin AS, Patel B, McNab AA, McCann JD, Leatherbarrow B, Malhotra R. Blepharoptosis surgery in patients with myasthenia gravis. Br J Ophthalmol 2015; 99:899-902. [DOI: 10.1136/bjophthalmol-2014-306335] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 12/26/2014] [Indexed: 11/03/2022]
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Fakiri MO, Tavy DL, Hama-Amin AD, Wirtz PW. Accuracy of the ice test in the diagnosis of myasthenia gravis in patients with ptosis. Muscle Nerve 2013; 48:902-4. [DOI: 10.1002/mus.23857] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2013] [Indexed: 11/09/2022]
Affiliation(s)
- M. Omeed Fakiri
- Department of Neurology; Haga Teaching Hospitals; Leyweg 275, 2545 CH The Hague The Netherlands
| | - Dénes L.J. Tavy
- Department of Neurology; Haga Teaching Hospitals; Leyweg 275, 2545 CH The Hague The Netherlands
| | - Ako Dara Hama-Amin
- Department of Neurology; Haga Teaching Hospitals; Leyweg 275, 2545 CH The Hague The Netherlands
| | - Paul W. Wirtz
- Department of Neurology; Haga Teaching Hospitals; Leyweg 275, 2545 CH The Hague The Netherlands
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Asamura S, Kakizaki H, Enjyo M, Hashimoto T, Isogai N. Frontalis sling procedure for ocular myasthenia gravis. Clin Ophthalmol 2012; 6:575-7. [PMID: 22553417 PMCID: PMC3340122 DOI: 10.2147/opth.s30612] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
A 39-year-old woman was diagnosed with myasthenia gravis when she was 8 years old. Although many treatments – such as cholinesterase inhibitors and steroids – had been given to the patient, her condition did not improve sufficiently. As she demonstrated bilateral 3 mm levator function without any eye movement disturbances, bilateral frontalis sling procedures were performed with an autologous fascia lata. One year after the operation, the operated upper eyelids showed symmetrically appropriate heights with good functional outcome. A sling procedure with an autologous fascia lata was suitable for correcting poor levator function of an ocular myasthenia gravis case.
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Affiliation(s)
- Shinichi Asamura
- Department of Plastic and Reconstructive Surgery, Kinki University School of Medicine, Osakasayama, Osaka, Japan
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