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Validity of Forced Eyelid Closure Test: A Novel Clinical Screening Test for Ocular Myasthenia Gravis

Apinyawasisuk, Supanut MD; Zhou, Xinkai MS; Tian, Jack J.; Garcia, Giancarlo A. AB; Karanjia, Rustum MD, PhD; Sadun, Alfredo A. MD, PhD

doi: 10.1097/WNO.0000000000000514
Original Contribution

Background: Forced eyelid closure test (FECT) is a clinical screening test developed from the original Cogan lid twitch (CLT) sign to assist in the diagnosis of ocular myasthenia gravis (OMG), We evaluated the sensitivity and specificity of FECT compared with CLT and benchmarked to standard diagnostic tests.

Methods: This study was a retrospective chart review of 48 patients using electronic medical records of those that presented with ptosis and/or diplopia at Doheny Eye Institute, University of California, Los Angeles between February 2015 and April 2016. Patients without FECT testing were excluded. FECT and CLT results, and final diagnosis were recorded. To perform FECT, the patient was asked to squeeze his or her eyelids shut for 5–10 seconds then open quickly and fixate in primary position. The excessive upward overshoot of eyelids movement indicated a positive FECT. The test was performed by a neuro-ophthalmologist before establishing the diagnosis. Patients who had equivocal test results and/or inconclusive final diagnosis were excluded.

Results: Of the 48 patients studied, 18 patients (37.5%) had positive FECT; 15 of whom had a final diagnosis of OMG (83.3%). Of the 30 patients with negative FECT, 1 had OMG (3.3%). Of the 48 patients, 35 patients also had a documented CLT result (72.9%). CLT was positive in 11 of these 35 patients (31.4%), and 9 of these 11 had OMG (81.8%). Of the 24 patients with negative CLT, 2 of them had OMG (8.3%). Sensitivity and specificity of FECT were 94% and 91% (joint 95% confidence region: sensitivity × specificity = [0.70, 1] × [0.75, 1]). The relative true-positive fraction (rTPF) between FECT and CLT was 1.15; the relative false-positive fraction was 1.31.

Conclusions: FECT is a simple clinical screening test with good sensitivity and specificity for OMG.

Supplemental Digital Content is Available in the Text.

Doheny Eye Center, Department of Ophthalmology (SA, JJT, GAG, RK, AAS), David Geffen School of Medicine, UCLA, Los Angeles, California; Ophthalmology Department (SA), King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Department of Ophthalmology (SA), Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Department of Medicine (XZ), Statistics Core, David Geffen School of Medicine at UCLA, Los Angeles, California; David Geffen School of Medicine (JJT), UCLA, Los Angeles, California; University of California-Irvine School of Medicine (GAG), Irvine, California; and The Ottawa Eye Institute (RK), Department of Ophthalmology University of Ottawa, Ottawa, Ontario, Canada.

Address correspondence to Supanut Apinyawasisuk, MD, 1873 Rama 4 Road, Pathumwan, Bangkok 10330, Thailand; E-mail:

The authors report no conflicts of interest.

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© 2017 by North American Neuro-Ophthalmology Society