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Correspondence to Dr Gunjan Saluja; [email protected]
Background
Ocular myasthenia can be a mystery to solve especially when the presentation is unusual. Ocular myasthenia can mimic any ophthalmoplegia, and diplopia may be absent in chronic cases. The case reminded us of this important clinical lesson that myasthenia must be suspected if the limitation of extraocular movements cannot be explained by any particular cranial nerve palsy. The suspicion can further be confirmed by simple bedside tests like ice pack test, sleep test and Cogan’s lid twitch sign.
Case presentation
A 24-year- old healthy man presented to the strabismus clinic of our institute with drooping of left eyelid, along with limitation of extraocular movements noticed by the patient since 3 years, and further worsening was noticed since 5 months. Patient gave a history of gradual deterioration of symptoms, there was no history of diplopia, dysphagia, muscle weakness, trauma, surgery or fever. On examination, patient had a visual acuity of 20/20 both eye, left eye had severe ptosis with a compensatory lid retraction in the right eye (figure 1), with severe limitation of extraocular movements in both eyes (figure 2) and a positive Cogan’s lid twitch sign (video 1).
Primary and secondary deviations were measured by modified Krimsky’s test in all nine gazes and were found to be incomitant, with right eye fixing the deviation was found to be 45 prism dioptre and with left eye fixing exodeviation was found to be 60 prism dioptre in primary position, and in downgaze the deviation with right eye fixing was 45 prism dioptre and with left eye fixing it was >70 prism dioptre. Other anterior segment and fundus examination findings were within normal limits.
Investigations
The gradual onset and progressive deterioration of symptoms raised a possibility of ocular myasthenia gravis, for which ice pack test...