Friday, April 19, 2024

Double Vision And Droopy Eyelid

Surgery For Ocular Myasthenia Gravis

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Most often, two different forms of surgery are used to treat ocular myasthenia gravis:

Strabismus surgery: This surgery is done on the muscles of the eyes in order to improve double vision and correct any underlying deviation of the eye . It might be done on patients whose myasthenia gravis does not appear to be progressing or in those whose eyes have a significant deviation.

During this surgery, a muscle that controls the eye is detached and then reattached so that it can better control the eyes movements. In some cases, the surgery may need to be repeated in order to fine-tune the eye alignment.

Blepharoptosis surgery: In some cases, medication or other therapies may not be effective for treating ptosis. In cases of persistent ptosis, blepharoptosissurgery may be considered to improve both the functioning of the eyelid and its cosmetic appearance. Some patients with ptosis may find their vision obstructed by the drooping eyelid, and are unable to read or drive.

During levator advancement or resection surgery, the eyelid droop is corrected by shortening the muscle that raises the eyelid. This is typically an outpatient surgery. The patient recovers at home, using ice packs on the eyes for a few days, followed by antibiotic eye and lubricating drops or ointment for one to three weeks.

History Of Myasthenia Gravis

Thomas Willis and Samuel Wilks along with their European colleagues, Erb and Goldflam, were the earliest to write about MG. In 1895, the term Myasthenia Gravis pseudo-paralytica was used by German physician, Jolly. Treatment of MG became possible in 1934, when in an episode described as The miracle at St. Alfege’s, Mary Walker treated a case of MG with physostigmine on the basis that MG symptoms were similar to those of curare poisoning. Simpson and Nastuck later elaborated the role of the immune system in the pathophysiology of MG independently, and Patrick and Lindstrom showed that rabbits immunized with purified muscle-like acetylcholine receptors developed MG-like symptoms.

Double Vision From Myasthenia Gravis

Myasthenia gravis is a rare autoimmune disease that affects approximately 60,000 people in the United States. Symptoms include diplopia , ptosis , muscle weakness, and trouble speaking or swallowing.

Ocular, or eye-related, MG symptoms often happen first before the disease progresses to its general form that affects other systems in the body. Like many autoimmune and rare diseases, MG is often misdiagnosed.

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Can You Prevent Double Vision

You can prevent double vision if you prevent the occurrence of underlying problems.

Here are some tips:

  • Managing diabetes. Diabetes patients who stick to their treatment regimens have a reduced risk of developing double vision. People who observe a balanced diet, and exercise regularly are far less likely to develop diabetes-related double vision.
  • Prevent cataract development. Wearing sunglasses, quitting smoking, and eating a balanced diet may help keep your eyes healthy and prevent cataracts.
  • Soothe dry eyes. Keep your eyes well-lubricated. Also, try to avoid eye strain caused by extended computer usage. This may contribute to dry eyes.
  • Prevent head injuries. Wear your seatbelt, helmet, or appropriate protective gear when in risky environments.

In this article

How Is Ocular Myasthenia Gravis Different From Generalized Myasthenia Gravis

What Are The Symptoms Of Myasthenia Gravis?

Ocular myasthenia gravis only affects the muscles that move the eyes and eyelids. The symptoms of ocular myasthenia gravis include double vision , trouble focusing, and drooping eyelids. On the other hand, generalized myasthenia gravis affects muscles throughout the body. In addition to visual symptoms, generalized myasthenia gravis may cause trouble speaking, trouble swallowing, and weakness in the arms or legs.

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Common Causes Of Ptosis

There are a variety of conditions that cause ptosis. In most cases, the underlying cause affects the muscles that control your eyelid movements.

The eyelid muscles are called the levator palpebrae and Mullers muscle. Other causes of ptosis are related to neurological conditions.

Types of ptosis are divided into two general groups, congenital or acquired. Congenital ptosis is present at birth, while acquired ptosis develops later on in life.

Antibodies And Ocular Mg

Only half of people with ocular MG test positive for the antibodies that cause MG. People with no detectable antibodies are referred to as seronegative. For those that do have detectable antibodies, AChR antibodies are the most common. LRP4 antibodies are the next most common.2

Titin and ryanodine or MuSK antibodies are very rare in someone with ocular MG. In fact, people with MuSK MG may not have any eye muscle weakness.1,2

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A Series Of Small Shocks

After the patient got Keungs urgent call, her daughter drove her to the emergency department at Yale New Haven Hospital, and she was admitted to the step-down unit. This is the section for patients who are not quite sick enough to need the I.C.U. but might get to that point before long. Every few hours a technician came in to measure the strength of her breathing. If it got too low, she would have to go to the I.C.U. and maybe end up on a breathing machine.

Keung wasnt certain that the patient had myasthenia. Her eyelid was always droopy, her vision always double. With M.G., he would expect those symptoms to worsen after using the muscle and improve after resting. And M.G. usually affected the muscles closest to the body. He would expect her shoulders to be weak, not her hands. Despite his uncertainty, he decided to start the treatment for M.G. He didnt want to risk having her become even weaker. She was given high-dose steroids and intravenous immunoglobulins to suppress the parts of the immune system attacking the connection between her nerves and her muscles.

The patient stayed in the hospital for nearly two weeks. That first night her breathing was so bad she almost ended up in the I.C.U. And there were days when her arms were so weak she couldnt even feed herself. Her daughters and granddaughters took turns coming to see her in the hospital to help her eat and care for herself.

What Does A Double Eyelid Look Like

Droopy Eyelid (Ptosis) Repair

Double eyelids feature a crease on the upper lid. For some, its a well-defined crease and very noticeable. For others, its slight and invisible without a close examination.

As someones face ages over time, the delicate skin surrounding their eyes loses its elasticity and relaxes. This causes their large eyes with well-defined creases to develop hooded lids or partial creases.

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Are You Concerned About Myasthenia Gravis

Early referral to a neurologist is essential for a good MG outcome, but there are many reasons a person can experience diplopia and ptosis. If you have developed double vision or drooping eyelids, its important to schedule a comprehensive eye exam as soon as possible.

Our kind and compassionate team of eye professionals is here to help you through any vision problem. We promise to work with you to find the right diagnosis and treatment plan. Call or text us today at 855-8522 to make an eye exam appointment.

Alignment Of The Images And The Direction That Results In The Most Separation

Questions should be asked to identify if the diplopia is horizontal, vertical, or oblique. Horizontal diplopia, without vertical separation, is related to the impaired neural control or function of the medial rectus muscle, the lateral rectus muscle, or both. The direction of gaze that increases the separation of the images can be helpful in determining which extraocular muscle is involved. The images are maximally separated when the direction of gaze is in the region of action of the paretic muscle. For example, left trochlear nerve palsy causes most image separation on right and downward gaze. Horizontal diplopia that occurs almost exclusively at near distance is strongly suggestive of convergence insufficiency.

Oblique separation with one image slightly tilted is indicative of either superior or inferior oblique muscle dysfunction. Pronounced image tilting may be seen in lateral medullary syndrome. Aniseikonia, a condition caused by notable discrepancy of the refractive errors between two eyes, gives rise to diplopia because one image is smaller than the other and superimposed.

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How To Treat Droopy Eyelid

Most cases of dermatochalasis and ptosis are corrected with surgery by an ophthalmologist, but the procedures will be different. Dermatochalasis is corrected by blepharoplasty, an eyelid revision procedure that removes excess skin and fat from the eyelid to improve vision and rejuvenate the appearance of the eye. Blepharoplasty restores a more youthful look to your face and opens up the eye by removal of excess tissue.

Ptosis surgery often involves tightening the levator muscles to lift your eyelids and improve your vision as well as your appearance. In very severe cases, your surgeon may attach the eyelid to the forehead to allow your forehead muscles to help the levator lift the eyelid. One side effect may be that your eyelids may not be exactly symmetrical even though the lids are higher than before surgery.

If you are experiencing droopy eyelids and you are noticing a difference in your vision, contact your eye care specialist for more information about the best course of treatment to improve your eyesight.

How Often Does Myasthenia Gravis Only Affect The Eyes


For about one half of patients with myasthenia gravis, the first symptoms are visual. About 15% of these patients will remain only having visual symptoms, even years after their diagnosis. In the other 85% of patients, however, symptoms of weakness will develop in another part of the body, usually within the next three years. At that time, these patients are considered to have generalized myasthenia gravis.

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Abnormalities Of Vertical Eye Movements

Disturbances of vertical gaze are usually associated with damage to either the posterior commissure, the vertical equivalent of the PPRF, the rostral interstitial nucleus of the medial longitudinal fasciculus , and the interstitial nucleus of Cajal, or a combination of these structures. Interpretation of limited vertical gaze should be undertaken with care because restricted upward gaze is seen in the normal elderly. Downward gaze palsy is usually pathologic and may be seen in brainstem lesions and certain neurodegenerative disorders such as progressive supranuclear palsy or adult Niemanns-Pick disease. Dorsal midbrain syndrome is caused by a lesion that affects the posterior commissure and results in skew deviation, light-near dissociation of pupil constriction, and convergenceretraction nystagmus, in addition to a vertical gaze palsy. The common causes are pineal tumour and hydrocephalus, and it can be secondary to drugs such as barbiturates, neuroleptics, and carbamazepine. When this syndrome is acute, the eyes are tonically deviated downwards , and this sign is well described in premature infants following intraventricular haemorrhage.

Eye Or Eyelid Conditions

Eye conditions can result in a drooping eyelid.

  • Infection: An infection of the eye socket can lead to eye pain, difficulty moving the eye, and a drooping eyelid.
  • Eyelid abnormality: A structural abnormality, such as a tumor or thickening caused by an allergic eye disease, can cause droopiness by weighing down the eyelid.

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How Is Droopy Eyelid Diagnosed

Your doctor will likely perform a physical exam and ask you about your medical history. Once youve explained how often your eyelids droop and the length of time this has been happening, your doctor will run some tests to find the cause.

They may perform a slit lamp exam so that your doctor can take a close look at your eye with the help of high-intensity light. Your eyes may be dilated for this exam, so you may experience some slight eye discomfort.

Another exam that can be used to diagnose issues such as droopy eyelid is the Tensilon test.

Your doctor may inject a drug called Tensilon, known generically as edrophonium, into one of your veins. You may be asked to cross and uncross your legs or stand up and sit down several times.

Your doctor will monitor you to see if the Tensilon improves your muscle strength. This will help them determine whether a condition called myasthenia gravis is causing the droopy eyelid.

What Medications Should Be Avoided

Eyelid Muscle Surgery

Certain medications can worsen the symptoms of myasthenia and should be avoided. These medications include specific antibiotics , beta-blockers, calcium channel blockers, and phenytoin . If a patient with myasthenia gravis requires a surgical procedure, the anesthesiologist should be aware and in order to use the proper medications.

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How Can Double Vision Be Treated

Double vision that results from myasthenia gravis is most often treated by blocking the vision from one eye. Either an eye patch can be worn or scotch tape can be placed over one lens in the eyeglasses. If one eyelid is very droopy and blocks the vision in that eye, the double vision will not require a separate treatment. Usually special glasses with prisms are not helpful because of the considerable fluctuation in the amount of double vision in patients with myasthenia gravis.

How To Fix Diplopia: Best Treatment Options

Finding the cause of the double vision is the most important step before deciding on the type of treatment appropriate for you.

Common treatment options for double vision include:

  • Corrective lenses. The visual issue may be corrected using eyeglasses or customized lenses. Prisms, for example, can be engraved into your eyeglass lenses to adjust your vision. When placed on one or both lenses, press-on prisms assist in realigning the eyes and eliminate temporary double vision. Prism lenses are carved into the eyeglasses in the case of permanent double vision.
  • Eye patch or cover. Double vision may be mitigated by covering one eye. While an eye cover may not be a long-term solution, it may help manage double vision until a more permanent solution is found.
  • Eye exercises. If strained or weaker eye muscles are the cause of your visual issue, your doctor may recommend exercises to help you restore eye muscle strength. Your vision problems should improve as your muscles strengthen.
  • Surgery. Depending on the cause, surgery may be required to address any physical problems. People who have cataracts or other eye disorders will almost certainly need surgery at some point. The surgical procedure to address that issue should also correct any double vision.
  • Botulinum toxin injections. Botox is injected into the eyes to cause relaxation of the muscles in the case of binocular diplopia.9

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What Causes Double Vision

Each eye forms a unique picture of its surroundings. The brain combines the information from each eye and interprets them as a single, distinct image.

Depth of field is created by combining the efforts of both eyes. Double imaging may be caused by damage to the muscles that move the eyes or the nerves that regulate eye movement.

Certain diseases may also impair the muscles that move the eyes, resulting in double vision.

Possible causes of monocular diplopia include:

  • Cataract which is prevalent among people above the age of 80 years3
  • Issues with corneashape, such as in the case of keratoconus or surface irregularity4
  • Dry eyeswhereby blinking becomes itchy and stingy
  • Lens dislocation, such as in the case of eye trauma

Possible causes of binocular diplopia include:

  • Diabetes can cause nerve damage in the eyes
  • Extraocular muscle damage such as in the case of head trauma, stroke, brain tumor, an eye tumor, or multiple sclerosis
  • Grave’s disease , which may cause thickening or swelling of eye socket muscles
  • Myasthenia gravis, which hinders the ability of the eye muscles to work properly

Swallowing Speaking And Breathing

Droopy Eyelids

If the weakness affects the muscles in the mouth, throat and chest, it can cause:

  • difficulty chewing
  • choking and accidentally inhaling bits of food, which can lead to repeated chest infections
  • shortness of breath, particularly when lying down or after exercise

Some people with myasthenia gravis also experience severe breathing difficulties, known as a “myasthenic crisis”.

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Identifying The Paretic Muscle

The range of eye movements is examined by asking the patient to follow a target, placed 50 cm away in order to avoid convergence, and the patient should be asked to report any diplopia during the examination. It is conventional to record cardinal eye positions in an H fashion from the patients perspective . This method helps identify the paretic muscle more clearly as each direction corresponds with the main action of a particular extraocular muscle. Subjective diplopia in the absence of visible ocular motility restriction should be further tested by occluding each eye in turn, and the general rule is that the outer image comes from the paretic eye. For example, if the patient reports diplopia in left gaze and the outer image disappears with right eye occluded, the patient has a right medial rectus palsy.

Figure 2

Conventional clinical recording of ocular motility. Each direction corresponds with the main action of each particular extraocular muscle. It is drawn from the patients perspective. MR, medial rectus LR, lateral rectus SR, superior rectus IR, inferior rectus SO, superior oblique IO, inferior oblique.

Parks three-step test has been commonly used for identifying the paretic muscle in vertical diplopia. The steps are as follows:

Although the range of eye movements on examination yields most information in identifying the paretic muscle, clues from general examination helps to confirm the abnormalities of eye movement and localise the disease process.

How To Tell If You Have Double Vision

It’s generally easy to distinguish between monocular and binocular double vision.

However, It may be more challenging to determine the cause. Your symptoms and visual experiences will help decide whether or not you have double vision.

When you go to the doctor, they’ll note your symptoms and do a few tests to rule out any other visual issues. They will also do a quick test to determine the kind of diplopia you have.

Once you’ve been diagnosed with diplopia, the search for a cause follows. When searching for the cause, your doctor will do the following:

  • Examine your current health status. Your doctor will discuss with you and take stock of the history of your symptoms, your personal health history, and that of your family.
  • Conduct a physical exam. A comprehensive physical examination can assist your doctor in determining the cause of your double vision. This examination may include blood tests, vision checks, toxicity tests, blood sugar tests and imaging .

Many instances of double vision resolve on their own. However, medical examination is recommended to keep track of the patient’s condition and further establish the level of impairment.7

Some patients may require MRI neuroimaging to identify abnormalities in the orbital, cranial, or central nervous systems .8

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