Myasthenia Gravis?

[OLDCOT]

I am a COT with 20 yrs experience.  I have recently taken a job in the optom dept of a large medical clinic.

Today we had a patient who has been on my mind.  I need advice.

Subjective: 76 year old patient presents c/o sudden painless loss of vision OS at 5 PM yesterday.  He also c/o problems keeping his eyes open, especially the OS, as well as difficulty with speech and gait since onset.  He has a hx of long standing IDDM, CVA June 2007 effecting speech.  He was seen in clinic 3 days ago and dilated exam revealed CSME OS > OD.  Retinal referal pending.  VA 12-3-07 was 20/30 OD, 20/200 OS.  Denies nausea or weakness of extremities.  Smile and frown appear symetrical.  Grip is even.  Admits mild headache since onset.  Hx glaucoma.  Cosopt BID OU.

Objective:
Vacc:
OD 20/50+2  PH NI
OS BHM      PH NI

Pupils: Square 2* 4 loop IOL OU.  Brisk.  No apparent APD.
EOM: Full ROM
CF: FTC (LUL manually raised while testing)

Significant ptosis OS>OD

TAPPL:  16/16 @ 1:00 PM

Dilation: 1%m & 2.5%p OU

Dr's findings reveal retinae and ONH are consistant with findings 3 days ago.  OCT confirms no change in CSME.

Dr referred patient to his PCP for further evaluation as no ocular explanation could be found for his visual loss.

I have seen a few cases of Myasthenia Gravis and his uneven ptosis brought this to mind.  His DM history contributed to the idea.  His wife stated that his ptosis was improved on waking this AM.  I have not seen a case with such dramatic loss of vision.

My question is, would it be prudent to mention this to my boss?  I know that MG is often missed.  The patient's stroke hx may make this likely.  At the same time, I do not want to aggravate or offend my boss.  

I should have just done an ice test and then wouldn't be sitting here typing.  

Does the sudden loss of vision rule out MG?  If not, should I mention this to my boss?  Any advice would be appreciated.

Thanks.

[John C Hagan III, MD, FACS, FAAO]

I would be happy to hear anything you felt llike saying  j hagan @ bizkc. rr. com      eliminate the spaces

JCH III MD

[OLDCOT]

I live in a neighboring state where things are a bit more complicated.  I can't say more in an open forum, lol.  Would be happy to trade email if you are interested.  

[John C Hagan III, MD, FACS, FAAO]

Our office is the largest in Kansas City  9 offices most with surgicenters. It's the best working relationship of Optoms and ophthalmologists I've ever seen. Mutual respect but the optoms don't try and do things they're not qualified to do. I'm more than happy to have the ODs do contacts.

JCH III MD

[OLDCOT]

Thank you for your flattering comment!  I'm honored.  

I attempted to reach this patient by phone off and on all day without success which suggests to me he was probably admitted.  Dr also told me this afternoon that he'd contacted the primary care dr this AM to recommend CRP and WSR be drawn, so he had similar thoughts to yours about temporal arteritis.  

I can't thank you enough for your respectful and prompt responses.  It's very difficult when starting work for a new dr to know what will upset him and what won't, so you saved me that stress.

Happy Holidays to you as well.  I'll keep you posted.

[John C Hagan III, MD, FACS, FAAO]

If you ever move to Kansas City let us know. We would be happy to find a place for such a skilled and concerned COT.

If you find a definitive diagnosis please let us know.

Merry Christmas.

JCH III MD

[OLDCOT]

CSME = clinically significant mac edema 2* diabetes
ONH = optic nerve head

Sorry for so many acronyms!

Boss did send him on to his primary care directly from our chair yesterday, in fact he had me call ahead to confirm they would see the patient immediately.  I have not heard anything more from the patient or family yet.  I'll let you know when I do.

Thank you for putting my mind at ease that we'd done the right thing.  I just wanted to be sure that an obscure dx possibility wasn't overlooked.  Thanks also for your prompt response.

[John C Hagan III, MD, FACS, FAAO]

What does the acronym  CSME stand for? Macular Edema?  a what is  ONH?  Ophthalmology is over-run with acronyms.  

Myasthenia Gravis (MG) (systemic nor ocular) does not causes loss of vision. The likelihood of the sudden onset of MG with these other symptoms is infinitely small and MG in my opinion isn't at all likely.


I suggest your boss treat this as an extreme emergency and get him to his family physician immediately. In my opinion he needs emergency admission and worked up for stroke or other neurological and vascular disorders by a neurologist and an ophthalmologist.
One thing that I would have done immediately is draw a C-reactive protein and a Sedimentation rate. Temporal arteritis (aka giant cell arteritis) should always be suspected in elderly individuals with loss of vision and other neurological events.

You would be doing the patient a favor if you build a fire under "you boss" to get this patient to a neurologist and ophthalmologist and in the hospital tomorrow as early as possible.

Let me know about the abbreviations And down the line what the final diagnosis did. I congratulate you for not leaving the poor man hanging.

JCH III MD