From the Guidelines
Ophthalmoparesis requires a comprehensive evaluation to determine the underlying cause, and treatment should be tailored to address the specific etiology, with the goal of preventing complications like permanent diplopia or visual impairment. When evaluating a patient with ophthalmoparesis, clinicians should first determine if the condition is isolated or part of a broader neurological presentation. Common causes include myasthenia gravis, thyroid eye disease, diabetic cranial neuropathy, multiple sclerosis, stroke, brain tumors, and mitochondrial disorders like chronic progressive external ophthalmoplegia.
Diagnostic Considerations
- A complete neurological examination is essential to identify any associated neurological deficits
- Thyroid function tests and acetylcholine receptor antibody testing may be indicated to rule out thyroid eye disease and myasthenia gravis, respectively
- MRI of the brain is crucial to evaluate for any structural lesions or abnormalities that may be contributing to the ophthalmoparesis, as recommended by the ACR Appropriateness Criteria 1
- Cerebrospinal fluid analysis or muscle biopsy may be necessary in certain cases to confirm the diagnosis
Treatment Options
- Treatment depends on the underlying cause, with options including pyridostigmine for myasthenia gravis (starting at 30-60mg three times daily), corticosteroids for inflammatory conditions, or specific management of conditions like diabetes or thyroid disease
- Surgical intervention may be necessary for strabismus correction after the condition has stabilized, with botulinum toxin injections or tenotomy procedures potentially useful for small-angle deviations 1
- Patients should be monitored for progression of symptoms, as ophthalmoparesis can sometimes be the initial manifestation of a progressive neurological disorder
Key Takeaways
- Prompt diagnosis and treatment are essential to prevent complications like permanent diplopia or visual impairment
- A multidisciplinary approach, including neurology, ophthalmology, and other specialties as needed, may be necessary to manage patients with ophthalmoparesis effectively, as suggested by the adult strabismus preferred practice pattern 1
From the Research
Considerations for Ophthalmoparesis
- Ophthalmoparesis can be caused by a wide range of diseases, including myasthenia gravis, and can be successfully treated if diagnosed correctly 2
- Clinical symptoms, extra-ocular muscle involvement patterns, and imaging features can provide valuable clues for diagnosis and follow-up of ptosis and ophthalmoparesis 2
- A comprehensive clinical examination can often provide enough information to determine the etiology of ophthalmoplegia, or at least rule out causes that can spare the patient from unnecessary tests 3
Diagnostic Techniques
- Measuring diplopia with prisms before and after pyridostigmine administration can help detect patients with suspected myasthenia gravis 4
- Orthoptic measurements, such as the Quantitative Myasthenia Gravis (QMG) score and palpebral fissure height (PFH) photography, can be used to quantify ocular myasthenia gravis symptoms 5
- The conventional and video Hess screen tests can be used to measure gaze deviations and assess the response to treatment 5
Treatment and Management
- Prednisone and pyridostigmine are commonly used treatments for ocular myasthenia gravis, with prednisone showing a higher efficacy in resolving ptosis and diplopia 6
- The response to treatment can vary between patients, and an individual approach is required to improve the quality of life of patients with myasthenia gravis 5
- Fluctuation in symptoms is a hallmark of myasthenia gravis, and understanding the dynamics of myasthenic symptoms is essential for diagnosis and anticipatory treatment 5