A 65-year-old male presents to your practice complaining of a left upper lid eye droop, which he notices more when he is tired. He also occasionally notices double vision after he has exercised. He noticed these problems about a year ago but they have been getting worse. Otherwise, he is healthy. What is going on?

The main feature is this presentation malfunction of extraocular muscles when the patient is fatigued. This sounds very much like ocular myasthenia gravis.

Myasthenia gravis is a rare autoimmune (immune system mistakenly attacks the body) condition that causes muscle weakness. It often affects the extraocular muscles as well as those muscles that are used to make facial expressions, swallow and speak. It can affect most parts of the body and can affect people of any age.

The symptoms get worse when the person is tired, worse at the end of the day or after exercise and better after sleep.

The main early symptoms are upper lid ptosis (bilateral but asymmetric) and diplopia. In 20% of sufferers, only the extraocular muscles are affected (ocular myasthenia) but in the other 80%, the effects spread to other parts in weeks, months or years. If symptoms have affected the eyes for 2 years or more the condition is unlikely then to affect other parts of the body.

This patient deserves to be referred to a medical practitioner for a formal diagnosis. Treatment is usually in the form of tablets that help improve the transmission of electrical signals from nerves to muscles or steroids to suppress the autoimmune response.

 

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