Slide Quiz 6
Shannon Crane
Case
– 67 year old white male presents to clinic as an urgent patient.
– Last dilated exam was 6 months ago.
– CC: Binocular vertical double vision and a droopy right eyelid which started about 3 weeks
ago. He states it is worse in the evening, and finds eye movements don't feel
as smooth as they should be.
– No ocular history.
Pertinent Medical History
– Hyperthyroid
–
Taking Methimazole
–
Last CT scan and MRI were normal showing no masses or orbital inflammation.
Case Cont.
–
Habitual Rx: +2.50 OTC readers
–
VA sc OD: 20/30 PH 20/20-
OS: 20/25 PH 20/20–
–
–
Pupils =PERRL-APD
EOM = full range of motion
Confrontations = FTFC OD/OS
–
Cover test
– Distance sc: 2-4 L Hypertropia
– Near cc: 2 PD L Hypertropia
SLIT LAMP EXAM:
Tonometry OD: 20 OS:
21 mmHg @ 11:00am
– Conjunctiva: white and quiet OU
– Cornea: arcus OU
– Anterior Chamber Deep & Quiet OU
– Lids/Lashes: See photo
– Ice pack test: See photo
– Iris: flat and intact OU
– Lens: 1+ NS OU
FUNDUS (undilated)
– C/D: 0.2/0.2 OU pink and healthy OU
– Macula: Flat and intact OU, (-) BFE
Ice pack test
Describe the photos.
Before
After
Patient states that diplopia is 100% resolved.
What are some differential
diagnoses?
Differential Diagnoses
– Ocular Myasthenia Gravis
– Grave’s Disease
– Horner’s Syndrome
– Lambert-Eaton Myasthenic Syndrome (LEMS)
– Cranial nerve 3 or 4 palsy
– Dermatochalasis
– Chronic progressive external ophthalmoplegia (CPEO)
Ocular Myasthenia Gravis
– Myasthenia Gravis is an autoimmune disease that target the Acetylcholine
receptors in the post-synaptic cleft for skeletal muscles.
– Systemic and ocular only cases (20-50%).
– Ptosis is the most frequent initial symptom, with diplopia being the second
most common symptom.
– No racial or geographic predilection, and can effect any age group.
– Non-emergent referral unless the patient is...