Skip to main content

Advertisement

SpringerLink
Log in

Ocular Myasthenia Gravis: Controversies and Updates

  • Neuroophthalmology (A Kawasaki, Section Editor)
  • Published:
Current Neurology and Neuroscience Reports Aims and scope Submit manuscript

Abstract

The majority of patients with myasthenia gravis (MG) initially present with ocular symptoms. An unresolved question is whether there are clinical features at onset to guide clinicians to predict an individual patient’s conversion risk from ocular MG (OMG) to generalized disease, or “secondary generalized MG” (SGMG), that is, a prognostic model. In light of the emerging theory that early corticosteroids may have a risk-modifying effect, the factors associated with secondary SGMG previously reported should be revisited. Studies showing potential risk-modifying effects of corticosteroids are useful, though flawed, owing to the heterogeneous retrospective studies and methods of reporting. Updates on other potential immunosuppressive agents are also discussed. Thymectomy in OMG has been recently reported in a few studies to be useful. MG associated with antibodies to muscle-specific kinase, usually associated with severe generalized MG, can cause a pure OMG syndrome. Recent serological developments in seronegative patients have also revealed antibodies to clustered anti-acetylcholine receptor and lipoprotein receptor-related protein-4.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Garlepp MJ, Dawkins RL, Christiansen FT, Lawton J, Luciani G, McLeod J, et al. Autoimmunity in ocular and generalised myasthenia gravis. J Neuroimmunol. 1981;1:325–32.

    Article  CAS  PubMed  Google Scholar 

  2. Vincent A, Palace J, Hilton-Jones D. Myasthenia gravis. Lancet. 2001;357:2122–8.

    Article  CAS  PubMed  Google Scholar 

  3. • Serra A, Ruff R, Kaminski H, Leigh RJ. Factors contributing to failure of neuromuscular transmission in myasthenia gravis and the special case of the extraocular muscles. Ann N Y Acad Sci. 2011;1233:26–33. This review summarizes the factors contributing to the increased susceptibility of the extraocular muscles to neuromuscular transmission failure.

    Article  PubMed  Google Scholar 

  4. Serra A, Ruff RL, Leigh RJ. Neuromuscular transmission failure in myasthenia gravis: decrement of safety factor and susceptibility of extraocular muscles. Ann N Y Acad Sci. 2012;1275:129–35.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  5. Sanmuganathan PS. Myasthenic syndrome of snake envenomation: a clinical and neurophysiological study. Postgrad Med J. 1998;74:596–9.

    Article  CAS  PubMed  Google Scholar 

  6. Bever CT, Aquino AV, Penn AS, Lovelace RE, Rowland LP. Prognosis of ocular myasthenia. Ann Neurol. 1983;14:516–9.

    Article  PubMed  Google Scholar 

  7. Ferguson FR, Hutchinson EC, Liversedge LA. Myasthenia gravis; results of medical management. Lancet. 1955;269:636–9.

    Article  CAS  PubMed  Google Scholar 

  8. Grob D, Brunner N, Namba T, Pagala M. Lifetime course of myasthenia gravis. Muscle Nerve. 2008;37:141–9.

    Article  PubMed  Google Scholar 

  9. Oosterhuis HJ. The natural course of myasthenia gravis: a long term follow up study. J Neurol Neurosurg Psychiatr. 1989;52:1121–7.

    Article  CAS  PubMed  Google Scholar 

  10. Evoli A, Tonali P, Bartoccioni E, Monaco LM. Ocular myasthenia: diagnostic and therapeutic problems. Acta Neurol Scand. 1988;77:31–5.

    Article  CAS  PubMed  Google Scholar 

  11. Grob D, Arsura EL, Brunner NG, Namba T. The course of myasthenia gravis and therapies affecting outcome. Ann N Y Acad Sci. 1987;505:472–99.

    Article  CAS  PubMed  Google Scholar 

  12. Kupersmith MJ. Ocular myasthenia gravis: treatment successes and failures in patients with long-term follow-up. J Neurol. 2009;256:1314–20.

    Article  PubMed  Google Scholar 

  13. Kupersmith MJ, Latkany R, Homel P. Development of generalized disease at 2 years in patients with ocular myasthenia gravis. Arch Neurol. 2003;60:243–8.

    Article  PubMed  Google Scholar 

  14. Mee J, Paine M, Byrne E, King J, Reardon K, O'Day J. Immunotherapy of ocular myasthenia gravis reduces conversion to generalized myasthenia gravis. J Neuroophthalmol. 2003;23:251–5.

    Article  PubMed  Google Scholar 

  15. Sommer N, Sigg B, Melms A, Weller M, Schepelmann K, Herzau V, et al. Ocular myasthenia gravis: response to long-term immunosuppressive treatment. J Neurol Neurosurg Psychiatr. 1997;62:156–62.

    Article  CAS  PubMed  Google Scholar 

  16. Kupersmith MJ, Moster M, Bhuiyan S, Warren F, Weinberg H. Beneficial effects of corticosteroids on ocular myasthenia gravis. Arch Neurol. 1996;53:802–4.

    Article  CAS  PubMed  Google Scholar 

  17. Monsul NT, Patwa HS, Knorr AM, Lesser RL, Goldstein JM. The effect of prednisone on the progression from ocular to generalized myasthenia gravis. J Neurol Sci. 2004;217:131–3.

    Article  CAS  PubMed  Google Scholar 

  18. Agius MA. Treatment of ocular myasthenia with corticosteroids: yes. Arch Neurol. 2000;57:750–1.

    Article  CAS  PubMed  Google Scholar 

  19. Chavis PS, Stickler DE, Walker A. Immunosuppressive or surgical treatment for ocular Myasthenia Gravis. Arch Neurol. 2007;64:1792–4.

    Article  PubMed  Google Scholar 

  20. Gilbert ME, De Sousa EA, Savino PJ. Ocular Myasthenia Gravis treatment: the case against prednisone therapy and thymectomy. Arch Neurol. 2007;64:1790–2.

    Article  PubMed  Google Scholar 

  21. Kaminski HJ, Daroff RB. Treatment of ocular myasthenia: steroids only when compelled. Arch Neurol. 2000;57:752–3.

    Article  CAS  PubMed  Google Scholar 

  22. Roach ES. Treating ocular Myasthenia Gravis with inadequate evidence. Arch Neurol. 2007;64:1794–5.

    Article  CAS  PubMed  Google Scholar 

  23. Grob D, Brunner NG, Namba T. The natural course of myasthenia gravis and effect of therapeutic measures. Ann N Y Acad Sci. 1981;377:652–69.

    Article  CAS  PubMed  Google Scholar 

  24. Steinberg AD, Krieg AM, Takashi T, Gourley MF. Timing of immunosuppression in the natural history of autoimmune diseases. J Autoimmun. 1992;5(Suppl A):197–203.

    Article  PubMed  Google Scholar 

  25. Grob D. Course and management of myasthenia gravis. J Am Med Assoc. 1953;153:529–32.

    Article  CAS  PubMed  Google Scholar 

  26. Kaplan I, Blakely BT, Pavlath GK, Travis M, Blau HM. Steroids induce acetylcholine receptors on cultured human muscle: implications for myasthenia gravis. Proc Natl Acad Sci U S A. 1990;87:8100–4.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  27. Askanas V, McFerrin J, Park-Matsumoto YC, Lee CS, Engel WK. Glucocorticoid increases acetylcholinesterase and organization of the postsynaptic membrane in innervated cultured human muscle. Exp Neurol. 1992;115:368–75.

    Article  CAS  PubMed  Google Scholar 

  28. Oosterhuis H, Bethlem J. Neurogenic muscle involvement in myasthenia gravis a clinical and histopathological study. J Neurol Neurosurg Psychiatr. 1973;36:244–54.

    Article  CAS  PubMed  Google Scholar 

  29. Barker L, Minakaran N, Patel L, Plant GT. Fixed ophthalmoplegia and extraocular muscle atrophy in acetylcholine receptor antibody-positive myasthenia gravis. Abstracts of the International Neuro-ophthalmology Society Meeting 2012. Neuro-ophthalmology. 2012;36(S1):47–8.

    Google Scholar 

  30. Okamoto K, Ito J, Tokiguchi S, Furusawa T. Atrophy of bilateral extraocular muscles. CT and clinical features of seven patients. J Neuroophthalmol. 1996;16:286–8.

    Article  CAS  PubMed  Google Scholar 

  31. Kupersmith MJ, Ying G. Ocular motor dysfunction and ptosis in ocular myasthenia gravis: effects of treatment. Br J Ophthalmol. 2005;89:1330–4.

    Article  CAS  PubMed  Google Scholar 

  32. Oosterhuis HJ. Observations of the natural history of myasthenia gravis and the effect of thymectomy. Ann N Y Acad Sci. 1981;377:678–90.

    Article  CAS  PubMed  Google Scholar 

  33. Caldwell JR, Furst DE. The efficacy and safety of low-dose corticosteroids for rheumatoid arthritis. Semin Arthritis Rheum. 1991;21:1–11.

    Article  CAS  PubMed  Google Scholar 

  34. Pascuzzi RM, Coslett HB, Johns TR. Long-term corticosteroid treatment of myasthenia gravis: report of 116 patients. Ann Neurol. 1984;15:291–8.

    Article  CAS  PubMed  Google Scholar 

  35. • Benatar M, Sanders DB, Wolfe GI, McDermott MP, Tawil R. Design of the efficacy of prednisone in the treatment of ocular myasthenia (EPITOME) trial. Ann N Y Acad Sci. 2012;1275:17–22. This article outlines the protocol of the first RCT (currently in progress) of corticosteroids in the treatment of ocular myasthenia.

    Article  CAS  PubMed  Google Scholar 

  36. Benatar M, Sanders DB, Burns TM, Cutter GR, Guptill JT, Baggi F, et al. Recommendations for myasthenia gravis clinical trials. Muscle Nerve. 2012;45:909–17.

    Article  PubMed  Google Scholar 

  37. Tackenberg B, Hemmer B, Oertel WH, Sommer N. Immunosuppressive treatment of ocular myasthenia gravis. BioDrugs. 2001;15:369–78.

    Article  CAS  PubMed  Google Scholar 

  38. • Kumar V, Kaminski HJ. Treatment of myasthenia gravis. Curr Neurol Neurosci Rep. 2011;11:89–96. This recent review summarizes the treatment and mechanisms of action of pharmaceutical treatment for MG.

    Article  CAS  PubMed  Google Scholar 

  39. Josephson MA, McKay DB. Women and transplantation: fertility, sexuality, pregnancy, contraception. Adv Chronic Kidney Dis. 2013;20:433–40.

    Article  PubMed  Google Scholar 

  40. Pedersen EG, Pottegård A, Hallas J, Friis S, Hansen K, Jensen PEH, et al. Use of azathioprine for non-thymoma myasthenia and risk of cancer: a nationwide case-control study in Denmark. Eur J Neurol. 2013;20:942–8.

    Article  CAS  PubMed  Google Scholar 

  41. Heckmann JM, Rawoot A, Bateman K, Renison R, Badri M. A single-blinded trial of methotrexate versus azathioprine as steroid-sparing agents in generalized myasthenia gravis. BMC Neurol. 2011;11:97.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  42. Ciafaloni E, Massey JM, Tucker-Lipscomb B, Sanders DB. Mycophenolate mofetil for myasthenia gravis: an open-label pilot study. Neurology. 2001;56:97–9.

    Article  CAS  PubMed  Google Scholar 

  43. Chaudhry V, Cornblath DR, Griffin JW, O'Brien R, Drachman DB. Mycophenolate mofetil: a safe and promising immunosuppressant in neuromuscular diseases. Neurology. 2001;56:94–6.

    Article  CAS  PubMed  Google Scholar 

  44. Meriggioli MN, Ciafaloni E, Al-Hayk KA, Rowin J, Tucker-Lipscomb B, Massey JM, et al. Mycophenolate mofetil for myasthenia gravis: an analysis of efficacy, safety, and tolerability. Neurology. 2003;61:1438–40.

    Article  CAS  PubMed  Google Scholar 

  45. Hehir MK, Burns TM, Alpers J, Conaway MR, Sawa M, Sanders DB. Mycophenolate mofetil in AChR-antibody-positive myasthenia gravis: outcomes in 102 patients. Muscle Nerve. 2010;41:593–8.

    Article  CAS  PubMed  Google Scholar 

  46. Sanders DB, Hart IK, Mantegazza R, Shukla SS, Siddiqi ZA, De Baets MHV, et al. An international, phase III, randomized trial of mycophenolate mofetil in myasthenia gravis. Neurology. 2008;71:400–6.

    Article  CAS  PubMed  Google Scholar 

  47. Muscle Study Group. A trial of mycophenolate mofetil with prednisone as initial immunotherapy in myasthenia gravis. Neurology. 2008;71:394–9.

    Article  Google Scholar 

  48. Tindall RS, Rollins JA, Phillips JT, Greenlee RG, Wells L, Belendiuk G. Preliminary results of a double-blind, randomized, placebo-controlled trial of cyclosporine in myasthenia gravis. N Engl J Med. 1987;316:719–24.

    Article  CAS  PubMed  Google Scholar 

  49. Tindall RS, Phillips JT, Rollins JA, Wells L, Hall K. A clinical therapeutic trial of cyclosporine in myasthenia gravis. Ann N Y Acad Sci. 1993;681:539–51.

    Article  CAS  PubMed  Google Scholar 

  50. Yoshikawa H, Kiuchi T, Saida T, Takamori M. Randomised, double-blind, placebo-controlled study of tacrolimus in myasthenia gravis. J Neurol Neurosurg Psychiatr. 2011;82:970–7.

    Article  PubMed  Google Scholar 

  51. Benatar M, Sanders D. The importance of studying history: lessons learnt from a trial of tacrolimus in myasthenia gravis. J Neurol Neurosurg Psychiatr. 2011;82:945.

    Article  PubMed  Google Scholar 

  52. Yagi Y, Sanjo N, Yokota T, Mizusawa H. Tacrolimus monotherapy: a promising option for ocular myasthenia gravis. Eur Neurol. 2013;69:344–5.

    Article  PubMed  Google Scholar 

  53. Gummert JF, Ikonen T, Morris RE. Newer immunosuppressive drugs: a review. J Am Soc Nephrol. 1999;10:1366–80.

    CAS  PubMed  Google Scholar 

  54. Schneider-Gold C, Hartung H-P, Gold R. Mycophenolate mofetil and tacrolimus: new therapeutic options in neuroimmunological diseases. Muscle Nerve. 2006;34:284–91.

    Article  CAS  PubMed  Google Scholar 

  55. • Mineo TC, Ambrogi V. Outcomes after thymectomy in class I myasthenia gravis. J Thorac Cardiovasc Surg. 2013;145:1319–24. This study showed that patients with ocular myasthenia treated with extended thymectomy achieved a more rapid remission than after non-surgical treatment. Significantly better outcomes resulted when thymectomy was performed within 6 months of onset of symptoms.

    Article  PubMed  Google Scholar 

  56. Hatton PD, Diehl JT, Daly BD, Rheinlander HF, Johnson H, Schrader JB, et al. Transsternal radical thymectomy for myasthenia gravis: a 15-year review. Ann Thorac Surg. 1989;47:838–40.

    Article  CAS  PubMed  Google Scholar 

  57. • Liu Z, Feng H, Yeung S-CJ, Zheng Z, Liu W, Ma J, et al. Extended transsternal thymectomy for the treatment of ocular myasthenia gravis. Ann Thorac Surg. 2011;92:1993–9. This study showed that extended transsternal thymectomy in OMG was safe and effective, particularly in patients with short duration of illness.

    Article  PubMed  Google Scholar 

  58. • Marulli G, Schiavon M, Perissinotto E, Bugana A, Di Chiara F, Rebusso A, et al. Surgical and neurologic outcomes after robotic thymectomy in 100 consecutive patients with myasthenia gravis. J Thorac Cardiovasc Surg. 2013;145:730–5. This article reported improved outcome in patients with ocular myasthenia treated with thymectomy.

    Article  PubMed  Google Scholar 

  59. Nakamura H, Taniguchi Y, Suzuki Y, Tanaka Y, Ishiguro K, Fukuda M, et al. Delayed remission after thymectomy for myasthenia gravis of the purely ocular type. J Thorac Cardiovasc Surg. 1996;112:371–5.

    Article  CAS  PubMed  Google Scholar 

  60. Schumm F, Wiethölter H, Fateh-Moghadam A, Dichgans J. Thymectomy in myasthenia with pure ocular symptoms. J Neurol Neurosurg Psychiatr. 1985;48:332–7.

    Article  CAS  PubMed  Google Scholar 

  61. Huang C-S, Hsu H-S, Huang B-S, Lee H-C, Kao K-P, Hsu W-H, et al. Factors influencing the outcome of transsternal thymectomy for myasthenia gravis. Acta Neurol Scand. 2005;112:108–14.

    Article  PubMed  Google Scholar 

  62. Masaoka A, Yamakawa Y, Niwa H, Fukai I, Kondo S, Kobayashi M, et al. Extended thymectomy for myasthenia gravis patients: a 20-year review. Ann Thorac Surg. 1996;62:853–9.

    Article  CAS  PubMed  Google Scholar 

  63. Papatestas AE, Pozner J, Genkins G, Kornfeld P, Matta RJ. Prognosis in occult thymomas in myasthenia gravis following transcervical thymectomy. Arch Surg. 1987;122:1352–6.

    Article  CAS  PubMed  Google Scholar 

  64. Roberts PF, Venuta F, Rendina E, De Giacomo T, Coloni GF, Follette DM, et al. Thymectomy in the treatment of ocular myasthenia gravis. J Thorac Cardiovasc Surg. 2001;122:562–8.

    Article  CAS  PubMed  Google Scholar 

  65. Shrager JB, Nathan D, Brinster CJ, Yousuf O, Spence A, Chen Z, et al. Outcomes after 151 extended transcervical thymectomies for myasthenia gravis. Ann Thorac Surg. 2006;82:1863–9.

    Article  PubMed  Google Scholar 

  66. Takanami I, Abiko T, Koizumi S. Therapeutic outcomes in thymectomied patients with myasthenia gravis. Ann Thorac Cardiovasc Surg. 2009;15:373–7.

    PubMed  Google Scholar 

  67. Sonett JR, Jaretzki A. Thymectomy for nonthymomatous myasthenia gravis: a critical analysis. Ann N Y Acad Sci. 2008;1132:315–28.

    Article  PubMed  Google Scholar 

  68. Chicaiza-Becerra LA, Garcia-Molina M, Gamboa O, Castañeda-Orjuela C. The cost-effectiveness of open or thoracoscopic thymectomy compared to medical treatment in managing Myasthenia gravis without thymomas. Rev Salud Publica (Bogota). 2012;14:260–70.

    Article  PubMed  Google Scholar 

  69. Newsom-Davis J, Cutter G, Wolfe GI, Kaminski HJ, Jaretzki A, Minisman G, et al. Status of the thymectomy trial for nonthymomatous myasthenia gravis patients receiving prednisone. Ann N Y Acad Sci. 2008;1132:344–7.

    Article  CAS  PubMed  Google Scholar 

  70. Evoli A, Tonali PA, Padua L, Monaco ML, Scuderi F, Batocchi AP, et al. Clinical correlates with anti-MuSK antibodies in generalized seronegative myasthenia gravis. Brain. 2003;126:2304–11.

    Article  PubMed  Google Scholar 

  71. McConville J, Farrugia ME, Beeson D, Kishore U, Metcalfe R, Newsom-Davis J, et al. Detection and characterization of MuSK antibodies in seronegative myasthenia gravis. Ann Neurol. 2004;55:580–4.

    Article  CAS  PubMed  Google Scholar 

  72. Oh SJ. Muscle-specific receptor tyrosine kinase antibody positive myasthenia gravis current status. J Clin Neurol. 2009;5:53–64.

    Article  PubMed Central  PubMed  Google Scholar 

  73. Sanders DB, El-Salem K, Massey JM, McConville J, Vincent A. Clinical aspects of MuSK antibody positive seronegative MG. Neurology. 2003;60:1978–80.

    Article  CAS  PubMed  Google Scholar 

  74. Zhou L, McConville J, Chaudhry V, Adams RN, Skolasky RL, Vincent A, et al. Clinical comparison of muscle-specific tyrosine kinase (MuSK) antibody-positive and -negative myasthenic patients. Muscle Nerve. 2004;30:55–60.

    Article  CAS  PubMed  Google Scholar 

  75. Vincent A, Leite MI. Neuromuscular junction autoimmune disease: muscle specific kinase antibodies and treatments for myasthenia gravis. Curr Opin Neurol. 2005;18:519–25.

    Article  CAS  PubMed  Google Scholar 

  76. Guptill JT, Sanders DB, Evoli A. Anti-MuSK antibody myasthenia gravis: clinical findings and response to treatment in two large cohorts. Muscle Nerve. 2011;44:36–40.

    Article  PubMed  Google Scholar 

  77. Bau V, Hanisch F, Hain B. Zierz S [Ocular involvement in MuSK antibody-positive myasthenia gravis]. Klin Monbl Augenheilkd. 2006;223:81–3 [in German].

    Article  CAS  PubMed  Google Scholar 

  78. Bennett DLH, Mills KR, Riordan-Eva P, Barnes PRJ, Rose MR. Anti-MuSK antibodies in a case of ocular myasthenia gravis. J Neurol Neurosurg Psychiatr. 2006;77:564–5.

    Article  CAS  PubMed  Google Scholar 

  79. Caress JB, Hunt CH, Batish SD. Anti-MuSK myasthenia gravis presenting with purely ocular findings. Arch Neurol. 2005;62:1002–3.

    PubMed  Google Scholar 

  80. Chan JW, Orrison WW. Ocular myasthenia: a rare presentation with MuSK antibody and bilateral extraocular muscle atrophy. Br J Ophthalmol. 2007;91:842–3.

    Article  PubMed  Google Scholar 

  81. Hanisch F, Eger K, Zierz S. MuSK-antibody positive pure ocular myasthenia gravis. J Neurol. 2006;253:659–60.

    Article  PubMed  Google Scholar 

  82. Hosaka A, Takuma H, Ohta K, Tamaoka A. An ocular form of myasthenia gravis with a high titer of anti-MuSK antibodies during a long-term follow-up. Intern Med. 2012;51:3077–9.

    Article  PubMed  Google Scholar 

  83. Zouvelou V, Papathanasiou A, Koros C, Rentzos M, Zambelis T, Stamboulis E. Pure ocular anti-MuSK myasthenia under no immunosuppressive treatment. Muscle Nerve. 2013;48:464.

    Article  PubMed  Google Scholar 

  84. Wong SH, Virgo JD, Plant G. Risks and benefits of corticosteroid therapy in ocular myasthenia gravis: a retrospective study. Abstracts of the European Neuro-Ophthalmology Society (EUNOS) 11th meeting. Neuro-ophthalmology. 2013;37(S1):107–8.

    Google Scholar 

  85. Leite MI, Jacob S, Viegas S, Cossins J, Clover L, Morgan BP, et al. IgG1 antibodies to acetylcholine receptors in “seronegative” myasthenia gravis. Brain. 2008;131:1940–52.

    Article  PubMed  Google Scholar 

  86. • Jacob S, Viegas S, Leite MI, Webster R, Cossins J, Kennett R, et al. Presence and pathogenic relevance of antibodies to clustered acetylcholine receptor in ocular and generalized myasthenia gravis. Arch Neurol. 2012;69:994–1001. This article shows that 50% of previously seronegative ocular myasthenia patients had complement-fixing IgG1-clustered AChR-antibodies, and demonstrated that their pathogenicity and the mechanisms seem similar to those of patients with typical AChR Abs.

    Article  PubMed  Google Scholar 

  87. • Higuchi O, Hamuro J, Motomura M, Yamanashi Y. Autoantibodies to low-density lipoprotein receptor-related protein 4 in myasthenia gravis. Ann Neurol. 2011;69:418–22. This article is the first to show that a proportion of seronegative MG patients have antibodies to LRP4, one of the essential proteins at the neuromuscular junction.

    Article  CAS  PubMed  Google Scholar 

  88. Pevzner A, Schoser B, Peters K, Cosma N-C, Karakatsani A, Schalke B, et al. Anti-LRP4 autoantibodies in AChR- and MuSK-antibody-negative myasthenia gravis. J Neurol. 2012;259:427–35.

    Article  CAS  PubMed  Google Scholar 

  89. Zhang B, Tzartos JS, Belimezi M, Ragheb S, Bealmear B, Lewis RA, et al. Autoantibodies to lipoprotein-related protein 4 in patients with double-seronegative myasthenia gravis. Arch Neurol. 2012;69:445–51.

    Article  PubMed  Google Scholar 

  90. Hoch W, McConville J, Helms S, Newsom-Davis J, Melms A, Vincent A, et al. Auto-antibodies to the receptor tyrosine kinase MuSk in patients with myasthenia gravis without acetycholine receptor antibodies. Nat Med. 2001;7(3)365–358.

    Google Scholar 

Download references

Acknowledgements

Saif Huda is supported by a Fellowship from the Watney Trust/Myasthenia Gravis Association and the Oxford NIHR Biomedical Research Centre. Dr Wong & Dr Plant have received bursaries from the Myasthenia Gravis Association for their work on Ocular Myasthrnia.

Compliance with Ethics Guidelines

ᅟ

Conflict of Interest

Sui H. Wong and Gordon T. Plant declare that they have no conflict of interest. Angela Vincent and the University of Oxford hold patents and receive royalties and payments for autoantibody tests including MuSK antibodies.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations

  1. Department of Neuro-ophthalmology, Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, UK

    Sui H. Wong & Gordon T. Plant

  2. Medical Eye Unit, St Thomas’ Hospital, London, UK

    Sui H. Wong & Gordon T. Plant

  3. Department of Neuro-ophthalmology, National Hospital for Neurology and Neurosurgery, London, UK

    Sui H. Wong & Gordon T. Plant

  4. Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK

    Saif Huda & Angela Vincent

Authors
  1. Sui H. Wong
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Saif Huda
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Angela Vincent
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Gordon T. Plant
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sui H. Wong.

Additional information

This article is part of the Topical Collection on Neuroophthalmology

Rights and permissions

Reprints and permissions

About this article

Cite this article

Wong, S.H., Huda, S., Vincent, A. et al. Ocular Myasthenia Gravis: Controversies and Updates. Curr Neurol Neurosci Rep 14, 421 (2014). https://doi.org/10.1007/s11910-013-0421-9

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11910-013-0421-9

Keywords

Search

Navigation