Ocular myasthenia: Missed Diagnosis in Neuro-Ophthalmology

Clinical Signs: exodeviation of the right eye, approximately 35 degrees; fixation is steady; visual acuity is 20/15 in both eyes; no fields effects; suppression of vision in right eye; horizontal gaze shows initial high velocity burst with dysmetria and low velocity drift; limited eye movement to approximately 5-10 degrees around primary; intersaccadic fatigue and ocular dysmetria. Presenting Symptom: upward flick of both lids with change of fixation (especially on upgaze); adaptation to ptosis by inclining head approximately 30 degrees backwards and slight furrowing of brow; twitch in both lids, though more prominent in right eye; musculature of lids not too abnormal, with mild weakness in resistance to opening. 28 year old male; history going back to 16 years of age with development of strabismus and ptosis; tensilon responsive and diagnosed as myasthenia; no results with mesterlone. Treatment: Edrophonium; Mesterolone. Disease/ Diagnosis: Myasthenia Gravis.