Comments on: Off-center presentation of ocular myasthenia : Kerala Journal of Ophthalmology

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Letter to the Editor

Comments on

Off-center presentation of ocular myasthenia

Babu, Anooja R

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Kerala Journal of Ophthalmology 34(3):p 291, Sep–Dec 2022. | DOI: 10.4103/kjo.kjo_126_22
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The case report “Off-center Presentation of Ocular Myasthenia” by Dr. Mary A. Stephen has highlighted the case report of a 70-year-old diabetic male who presented with diplopia.[1] The article brilliantly described a presentation of ocular myasthenia and highlighted the need for a high degree of suspicion for timely diagnosis of ocular Myasthenia Gravis. In this case, the initial diagnosis of diabetic mononeuropathy changed to ocular myasthenia when the initial presentation of unilateral ptosis gradually evolved to bilateral ptosis. Early detection of myasthenia is important as the management of diabetic mononeuropathy is entirely different from that of myasthenia, which the author achieved by meticulous examination of the patient and by timely clinical suspicion.

From an academic point of view, the few points that I would like to contribute include:

  1. Thoracic imaging like MRI or CT scan could have been done to detect thymoma, as it is present in 15% of cases.[23]
  2. Testing for striational antibodies can help determine the severity as it is a marker of severe Myasthenia Gravis (MG). Nearly all patients with MG and thymoma and half of the late-onset MG subgroup demonstrate the presence of striational antibody.[4]
  3. In seropositive cases, the titers of AchR (Acetylcholine Receptor) antibody are found to be significantly higher in patients who progressed to generalized disease than those whom it remained as ocular.[5]

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1. Stephen MA, Jayasri P, Harigaravelu PJ. Off-center presentation of ocular myasthenia Kerala J Ophthalmol. 2022;34:164–6
2. O'Hare M, Doughty C. Update on ocular myasthenia gravis Semin Neurol. 2019;39:749–60
3. Fortin E, Cestari DM, Weinberg DH. Ocular myasthenia gravis: An update on diagnosis and treatment Curr Opin Ophthalmol. 2018;29:477–84
4. Nair AG, Patil-Chhablani P, Venkatramani DV, Gandhi RA. Ocular myasthenia gravis: A review Indian J Ophthalmol. 2014;62:985–91
5. Kusner LL, Puwanant A, Kaminski HJ. Ocular myasthenia: Diagnosis, treatment, and pathogenesis Neurologist. 2006;12:231–9
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