Ocular myasthenia gravis: A review

Nair, Akshay Gopinathan; Patil-Chhablani, Preeti; Venkatramani, Devendra V; Gandhi, Rashmin Anilkumar

doi:10.4103/0301-4738.145987

Cited by 95 publications

(68 citation statements)

References 66 publications

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“…Therefore, despite adequate ACh release, end-plate action potentials fail to trigger muscle action potentials resulting in muscular paresis [2]. A large population of patients with systemic MG also have ocular involvement that can occur either initially or later during the clinical course of the disease [10].…”

Section: Discussionmentioning

confidence: 99%

“…As a result, they are more vulnerable to fatigue and exhaustion. Additionally, tonic muscle fibers are critical to sustainment of ocular gaze [10].…”

Section: Discussionmentioning

confidence: 99%

“…The ice test is not necessarily diagnostic but can raise the suspicion of MG [1,2]. The sleep test evaluates for resolution of ptosis or ophthalmoparesis immediately after a 30-minute period of sleep [10].…”

Section: Discussionmentioning

confidence: 99%

“…If titers are negative, as they are in about 30%-77% of cases, electromyography with repetitive nerve stimulation or single-fiber electromyography is necessary in order to establish a diagnosis. If the above studies are negative, MRI of the brain and lumbar puncture with CSF analysis may be warranted to exclude further inflammatory or structural pathology of the central nervous system [10].…”

Section: Discussionmentioning

confidence: 99%

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Pembrolizumab-Induced Ocular Myasthenic Crisis

Lorenzo¹,

Fitzpatrick²,

Campdesuner³

et al. 2020

Cureus

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Pembrolizumab, one of many novel immune checkpoint inhibitors (ICPi), is a monoclonal antibody that enhances immunity against cancer cells. Extensive escalation in immune activity predisposes to unsought immune-related adverse events. Due to progressive mesothelioma, a 67-year-old man was referred to the research unit and enrolled in a clinical trial with a cluster of differentiation (CD) 27 chemotherapeutic agent. He began crossover treatment and received just two doses of pembrolizumab, 33 and 16 days prior to admission. He subsequently presented to the emergency department with three days of acute onset severe diplopia and a drooping left eye. Acetylcholine receptor (AChR) antibodies returned positive at 13.9 nmol/L, and a diagnosis of ocular myasthenia gravis (OMG) was made. During his hospitalization, the patient was managed with methylprednisolone 80 mg intravenously daily, with conversion to prednisone 60 mg by mouth daily at time of discharge. Neuro-ophthalmology consultation was sought in the outpatient setting, and the patient was started on pyridostigmine. He was readmitted two weeks later with symptoms of progressive diffuse weakness, unsteady gait, and dysphagia, all in the setting of persistent diplopia. Intravenous immunoglobulin (IVIG) was promptly initiated, in addition to the pyridostigmine previously initiated in the outpatient setting. Unfortunately, after three IVIG treatments, the patient had experienced little improvement in his symptoms, and therefore elected hospice care. Although ICPis have revolutionized the management of a multitude of malignancies, recognition of immune-related adverse events is of critical importance.

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Section: Discussionmentioning

confidence: 99%

“…As a result, they are more vulnerable to fatigue and exhaustion. Additionally, tonic muscle fibers are critical to sustainment of ocular gaze [10].…”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

Pembrolizumab-Induced Ocular Myasthenic Crisis

Lorenzo¹,

Fitzpatrick²,

Campdesuner³

et al. 2020

Cureus

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“…“Sunrouge” water extract suppressed acetylcholinesterase activity in human neuroblastoma SK-N-SH cells [ 15 ]. Neostigmine methyl sulfate, which is an acetylcholinesterase inhibitor, is used as an eye-focusing medicine [ 21 ].…”

Section: Introductionmentioning

confidence: 99%

A Randomized, Placebo-Controlled Study on the Safety and Efficacy of Daily Ingestion of Green Tea (Camellia sinensis L.) cv. “Yabukita” and “Sunrouge” on Eyestrain and Blood Pressure in Healthy Adults

et al. 2018

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The green tea (Camellia sinensis L.) cultivar “Sunrouge” contains anthocyanins, catechins and flavonols. To determine whether ingesting green tea containing anthocyanins improves visual function and blood pressure (BP) in healthy adults, a randomized, double-blind, placebo-controlled study was performed. A total of 120 healthy subjects, aged between 20 and 60 years and with a systolic BP (SBP) value of ≤125 and <155 and a diastolic BP (DBP) value <95, or a DBP of ≤75 mmHg and <95 mmHg and a SBP <155 mmHg, were randomly assigned to one of three groups. For 12 weeks, the placebo group received barley extract without catechin; another group received “Sunrouge” extract containing 11.2 mg anthocyanin and 323.6 mg epigallocatechin-3-O-gallate (EGCG); and a third group received “Yabukita” extract containing 322.2 mg EGCG. Home BP, accommodation ability, visual analog scale questionnaires for eyestrain, and metabolic-associated markers were analyzed at weeks 0, 4, 8, and 12 of the intake period. The ingestion of “Sunrouge” tea significantly improved accommodation ability and eyestrain in subjects younger than 45 years and in subjects who operated visual display terminals every day. It also elevated BP. “Yabukita” tea ingestion significantly increased serum adiponectin levels. No adverse effects were observed. We conclude that long-term intake of “Sunrouge” tea containing anthocyanins and flavonols might improve visual function.

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Clinical and imaging clues to the diagnosis and follow‐up of ptosis and ophthalmoparesis

Keene

Kan

Meeren

et al. 2022

J cachexia sarcopenia muscle

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Ophthalmoparesis and ptosis can be caused by a wide range of rare or more prevalent diseases, several of which can be successfully treated. In this review, we provide clues to aid in the diagnosis of these diseases, based on the clinical symptoms, the involvement pattern and imaging features of extra‐ocular muscles (EOM). Dysfunction of EOM including the levator palpebrae can be due to muscle weakness, anatomical restrictions or pathology affecting the innervation. A comprehensive literature review was performed to find clinical and imaging clues for the diagnosis and follow‐up of ptosis and ophthalmoparesis. We used five patterns as a framework for differential diagnostic reasoning and for pattern recognition in symptomatology, EOM involvement and imaging results of individual patients. The five patterns were characterized by the presence of combination of ptosis, ophthalmoparesis, diplopia, pain, proptosis, nystagmus, extra‐orbital symptoms, symmetry or fluctuations in symptoms. Each pattern was linked to anatomical locations and either hereditary or acquired diseases. Hereditary muscle diseases often lead to ophthalmoparesis without diplopia as a predominant feature, while in acquired eye muscle diseases ophthalmoparesis is often asymmetrical and can be accompanied by proptosis and pain. Fluctuation is a hallmark of an acquired synaptic disease like myasthenia gravis. Nystagmus is indicative of a central nervous system lesion. Second, specific EOM involvement patterns can also provide valuable diagnostic clues. In hereditary muscle diseases like chronic progressive external ophthalmoplegia (CPEO) and oculo‐pharyngeal muscular dystrophy (OPMD) the superior rectus is often involved. In neuropathic disease, the pattern of involvement of the EOM can be linked to specific cranial nerves. In myasthenia gravis this pattern is variable within patients over time. Lastly, orbital imaging can aid in the diagnosis. Fat replacement of the EOM is commonly observed in hereditary myopathic diseases, such as CPEO. In contrast, inflammation and volume increases are often observed in acquired muscle diseases such as Graves' orbitopathy. In diseases with ophthalmoparesis and ptosis specific patterns of clinical symptoms, the EOM involvement pattern and orbital imaging provide valuable information for diagnosis and could prove valuable in the follow‐up of disease progression and the understanding of disease pathophysiology.

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Ocular myasthenia gravis: A review

Cited by 95 publications

References 66 publications

Pembrolizumab-Induced Ocular Myasthenic Crisis

Pembrolizumab-Induced Ocular Myasthenic Crisis

A Randomized, Placebo-Controlled Study on the Safety and Efficacy of Daily Ingestion of Green Tea (Camellia sinensis L.) cv. “Yabukita” and “Sunrouge” on Eyestrain and Blood Pressure in Healthy Adults

Clinical and imaging clues to the diagnosis and follow‐up of ptosis and ophthalmoparesis

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