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LETTER TO EDITOR
Year : 2003  |  Volume : 51  |  Issue : 2  |  Page : 283-284

Management of ocular myasthenia gravis coexisting with thyroid ophthalmopathy


Department of Neurological Sciences, Christian Medical College Hospital, Vellore, Tamilnadu-632004

Correspondence Address:
Department of Neurological Sciences, Christian Medical College Hospital, Vellore, Tamilnadu-632004
[email protected]



How to cite this article:
Kumar S. Management of ocular myasthenia gravis coexisting with thyroid ophthalmopathy . Neurol India 2003;51:283-4


How to cite this URL:
Kumar S. Management of ocular myasthenia gravis coexisting with thyroid ophthalmopathy . Neurol India [serial online] 2003 [cited 2023 Feb 6];51:283-4. Available from: https://www.neurologyindia.com/text.asp?2003/51/2/283/1114


Sir,
I read with interest the recent article by Yaman A et al.[1] They have described their experience of managing a case of ocular myasthenia gravis in association with thyroid ophthalmopathy. However, I would like to make certain observations.
Firstly, they have performed thymectomy for ocular myasthenia. Patients with ocular myasthenia have been noted to have poor prognosis after thymectomy.[2] Therefore, thymectomy is not recommended for patients with myasthenia gravis who belong to Ossermann Class I (ocular symptoms alone).[3] In the present case, if there was a suspicion of malignant thymoma, though unlikely, a biopsy could have been performed and thymectomy avoided. Also, the patient in this case received two sessions of plasmapheresis. There was no clear indication for the same. She had ocular symptoms alone that had responded well to medical therapy with pyridostigmine. There are specific indications of plasmapheresis in the treatment of myasthenia gravis- namely myasthenic crisis, chronic myasthenic patients who fail to respond adequately to conventional medical therapy and preoperatively in patients with poorly controlled disease.[3]
They conclude in their paper that ptosis is an unexpected symptom in thyroid ophthalmopathy. However, in an earlier report,[4] 60% of patients (six out of ten studied) with thyroid ophthalmopathy were found to have ptosis. In two of them, the ptosis was fluctuating in nature too. Interestingly, fluctuating ptosis, in addition to myasthenia gravis and thyroid ophthalmopathy, may also be found in mitochondrial myopathies and ptosis secondary to intracranial pathology such as dorsal midbrain glioma.[5] Ptosis in thyroid ophthalmopathy may be a 'pseudoptosis' secondary to eyelid retraction in the other eye or in some cases, it may be true ptosis.[4]
In conclusion, plasmapheresis and thymectomy are not recommended for ocular myasthenia, which otherwise responds well to medical therapy with pyridostigmine. Ptosis may occur in cases of thyroid ophthalmopathy without associated ocular myasthenia.
 

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1.Tellez-Zenteno JF, Remes-Troche JM, Garcia-Ramos G, Estanol B, Garduno-Espinoza J. Prognostic factors of thymectomy in patients with myasthenia gravis: a cohort of 132 patients. Eur Neurol 2001;46:171-7.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Sanders DB, Scoppetta C. The treatment of patients with myasthenia gravis. Neurol Clin 1994;12:343-68.  Back to cited text no. 2  [PUBMED]  
3.Batocchi AP, Evoli A, Majolini L, Lo Monaco M, Padua L, Ricci E, et al. Ocular palsies in the absence of other neurological or ocular symptoms: analysis of 105 cases. J Neurol 1997;244:639-45.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Ragge NK and Hoyt WF. Midbrain myasthenia: fatigable ptosis, 'lid twitch' sign, and ophthalmoparesis from a dorsal midbrain glioma. Neurology 1992;42:917-9.   Back to cited text no. 4    

 

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