Clinical question for the ODs

[ProZackMI]

As many of you know, I'm an MD (psychiatrist) with a background in internal medicine as well. However, ophthalmology was never my strong point. One of my good friends is a dentist who's wife is undergoing some visual problems. She recently had a neuro exam and here were the findings. No dx was made, as of yet, and no tx plans were discussed.

A 35 year-old female with a year long h/o ptosis and strabismus OU. Recent lab work was + for acetylcholine receptor antibodies (0.9). A CT of the brain was WNL. No h/o diplopia, dysphagia, or dysarthria, although she does have an intermittent Cogan's OS. PERRLA. VA sc 20/25 OU. VF WNL. She does have some ophthalmoplegia OS.

It's been a while, but to me, it sounds like it might be ocular myasthenia gravis. What do you think? Any recommendations or ideas? I referred her to a neuro-ophthalmologist at the Univ. of Mich Med. Center. In the past, I remember similar sxs being treated with Mestinon (~ 90 mgs QID), with improvement post pharm tx. It's been awhile, but this is my take on her sxs. Her treating neuro hasn't rendered a dx yet.

Ideas?

---

Members don't see this ad.

 

[Ben Chudner]

As many of you know, I'm an MD (psychiatrist) with a background in internal medicine as well. However, ophthalmology was never my strong point. One of my good friends is a dentist who's wife is undergoing some visual problems. She recently had a neuro exam and here were the findings. No dx was made, as of yet, and no tx plans were discussed.

A 35 year-old female with a year long h/o ptosis and strabismus OU. Recent lab work was + for acetylcholine receptor antibodies (0.9). A CT of the brain was WNL. No h/o diplopia, dysphagia, or dysarthria, although she does have an intermittent Cogan's OS. PERRLA. VA sc 20/25 OU. VF WNL. She does have some ophthalmoplegia OS.

It's been a while, but to me, it sounds like it might be ocular myasthenia gravis. What do you think? Any recommendations or ideas? I referred her to a neuro-ophthalmologist at the Univ. of Mich Med. Center. In the past, I remember similar sxs being treated with Mestinon (~ 90 mgs QID), with improvement post pharm tx. It's been awhile, but this is my take on her sxs. Her treating neuro hasn't rendered a dx yet.

Ideas?

Zack, I am a little confused on the history. The patient has a year long history of strab, but no diplopia. Are you sure her strab was not congenital? The typical presenting symptoms for ocular MG are intermittent ptosis and intermittent diplopia, although they can both be constant depending on the severity of the condition. The symptoms would be worse towards the end of the day. The Cogan's points to MG, as does the ach receptor antibodies. I would assume the neuro is looking in that direction based on the tests that were ordered. Mestinon can be very successful, as long as MG is the correct diagnosis. Did the neuro order a Tensilon test? If not, you can have your dentist friend perform the poor man's Tensilon test. Simply apply a very cold (as in ice cold) wash rag to the patient's eyes. If the ptosis temporarily resolves, that's a positive result.

 

[ProZackMI]

Zack, I am a little confused on the history. The patient has a year long history of strab, but no diplopia. Are you sure her strab was not congenital? The typical presenting symptoms for ocular MG are intermittent ptosis and intermittent diplopia, although they can both be constant depending on the severity of the condition. The symptoms would be worse towards the end of the day. The Cogan's points to MG, as does the ach receptor antibodies. I would assume the neuro is looking in that direction based on the tests that were ordered. Mestinon can be very successful, as long as MG is the correct diagnosis. Did the neuro order a Tensilon test? If not, you can have your dentist friend perform the poor man's Tensilon test. Simply apply a very cold (as in ice cold) wash rag to the patient's eyes. If the ptosis temporarily resolves, that's a positive result.

Based on what my friend told me, she didn't have any diplopia at all. That's what confused me too, but everything else points to MG. I'll ask about the Tensilon. I was trying to piece this together over the phone and just jotted a few notes. He didn't know what half of this stuff meant.

It sounds like it probably is MG. Question is, if it is, and the Mestinon is successful, would she be able to work? She's a real estate broker/agent. Thanks for the feedback.
Zack

 

[UABopt]

Zack, I am a little confused on the history. The patient has a year long history of strab, but no diplopia. Are you sure her strab was not congenital? The typical presenting symptoms for ocular MG are intermittent ptosis and intermittent diplopia, although they can both be constant depending on the severity of the condition. The symptoms would be worse towards the end of the day. The Cogan's points to MG, as does the ach receptor antibodies. I would assume the neuro is looking in that direction based on the tests that were ordered. Mestinon can be very successful, as long as MG is the correct diagnosis. Did the neuro order a Tensilon test? If not, you can have your dentist friend perform the poor man's Tensilon test. Simply apply a very cold (as in ice cold) wash rag to the patient's eyes. If the ptosis temporarily resolves, that's a positive result.

Dr. Chudner-

Am I correct in saying that it would be very unusual for a patient with a sudden onset strabismus, whatever the cause, not to have diplopia? Certainly a patient that has a congenital tropia may be able to suppress, but I would think that a patient with ocular MG would not be able to do the same. In any case it most definitely would not be possible to have a tropia and not have diplopia, unless one is suppressing (a trope is by definition not able to fuse). I would be interested to see what the results of a W4Dot, or a Stereo test would be on this patient.

I’d be surprised if a Tensilon test had not been ordered if MG was suspected. While I believe the course of MG is variable, I don’t think a diagnosis with the disease would necessarily mean she would have to quite her job. In fact, we have a professor at UABSO who has MG. While I don’t believe he drives any longer, he is still very functional, actively teaching and researching.

 

[Ben Chudner]

Dr. Chudner-

Am I correct in saying that it would be very unusual for a patient with a sudden onset strabismus, whatever the cause, not to have diplopia? Certainly a patient that has a congenital tropia may be able to suppress, but I would think that a patient with ocular MG would not be able to do the same. In any case it most definitely would not be possible to have a tropia and not have diplopia, unless one is suppressing (a trope is by definition not able to fuse).

You are correct.

I’d be surprised if a Tensilon test had not been ordered if MG was suspected.

I agree. Zack didn't say it wasn't ordered only that he didn't know if it was ordered. Also, a positive Ach receptor antibody test may be enough for a diagnosis for the neuro doc.

While I believe the course of MG is variable, I don’t think a diagnosis with the disease would necessarily mean she would have to quite her job. In fact, we have a professor at UABSO who has MG. While I don’t believe he drives any longer, he is still very functional, actively teaching and researching.

I agree.

 

[heatfenn]

I'm not an OD, but an orthoptist who has run cross a few cases of MG. I agree with you all in saying that this does appear to be consistent with ocular MG, with the exception of her lack of diplopia. As one of you mentioned, lack of diplopia with MG is rare, however if it was a congenital strab, then suppression could explain that (although if the strab varied with the MG, then it is possible that this could change the angle and move her out of her suppression zone, thus causing diplopia). Diplopia, although common to MG, would not be the deciding factor.....I've seen two patients with ocular MG that had only a slight strab (still able to fuse intermittently), Cogan's and increasing ptosis with fatigue. Hopefully they confirm her Dx soon....it sounds like they have all the pieces (ACh antibodies, etc.).

 

[Tom_Stickel]

Wait a second. First Zack says he'd only go to an optometrist for glasses or contacts, and only go to an MD for an eye condition.

Then he posts this clinical question in the OD forum and not the ophtho forum? You're not just testing us, are you Zack?

 

[ProZackMI]

Wait a second. First Zack says he'd only go to an optometrist for glasses or contacts, and only go to an MD for an eye condition.

Then he posts this clinical question in the OD forum and not the ophtho forum? You're not just testing us, are you Zack?

First, I know more people here than I do there. Second, in a roundabout way, I guess I am testing you guys. I know enough ocular path to get by, but this is definitely not my area of expertise. I still had a hunch it was ocular MG, but I really wasn't completely sure. I thought I would pose the sxs and see what you guys thought. I think most of you know much more than me on this subject matter.

Maybe, just maybe, you guys changed my outlook on optometry? So, as a result, I'll apologize to every OD and OD student on here (except gsinn-what's his name) and say I stand corrected. I'll let you know the results of my friend's wife's neuro-ophth exam when I find out.

Zack

 

[Envision]

First, I know more people here than I do there. Second, in a roundabout way, I guess I am testing you guys. I know enough ocular path to get by, but this is definitely not my area of expertise. I still had a hunch it was ocular MG, but I really wasn't completely sure. I thought I would pose the sxs and see what you guys thought. I think most of you know much more than me on this subject matter.

Maybe, just maybe, you guys changed my outlook on optometry? So, as a result, I'll apologize to every OD and OD student on here (except gsinn-what's his name) and say I stand corrected. I'll let you know the results of my friend's wife's neuro-ophth exam when I find out.

Zack

very cool

 

[chester]

Could there be a thyroid problem?

 

[rkl_OD2be]

Maybe, just maybe, you guys changed my outlook on optometry? So, as a result, I'll apologize to every OD and OD student on here (except gsinn-what's his name) and say I stand corrected. I'll let you know the results of my friend's wife's neuro-ophth exam when I find out.

I've got a new respect for you now...After your "ODs are technicians with degree inflation" remarks, this admission is huge in my view. Perhaps I could have been more tactful in my rebuttals to your posts...

Welcome to the forum, and thanks for the friendly, spirited debate.

 

[cpw]

Wait a second. First Zack says he'd only go to an optometrist for glasses or contacts, and only go to an MD for an eye condition.

Then he posts this clinical question in the OD forum and not the ophtho forum? You're not just testing us, are you Zack?

i had the same exact thought... but, I was holding off on posting to see how this panned out. And now I know !! .. (and knowing is half the battle!) [/GIJoe]