Ptosis - MG?

[J0611]

Hi,  I realized several months ago that my left eyelid was showing more than the right.  Looking back to pictures, it looks to have started about 5 years ago, but I guess I had never noticed.  I have been to doctors, opthalmologists, neurologists...had a brain/orbit MRI, a sinus CT, a chest Xray...had blood tests for thyroid problems, Graves disease, and Myasthenia Gravis.  All came back normal.

My eyelid is normal in the morning, but then stretches throughout the day.  Sometimes it is stretched when I wake up.  Last week, it was normal for 7 days straight (slightly worse at night), but then horrible for 7 days.  There is no pattern.  The only consistent thing is that once it droops, it does not get better until the next morning (and even sometimes then it is not better).  It seems worse when my eyes are really dry.  When I cry or put in eyedrops, my eyelid returns to normal for a few minutes.  I should add I was an 18 year contact wearer that wore my glasses.  My eyesight is horrible, but I have been wearing glasses for the past few months because of this.

It never droops over my pupil and actually seems to remain at the same level even when normal.  My eyelid doesn't appear to droop much lower than my normal eyelid, but the crease just gets higher and higher.  The doctor said I still may have ocular myasthenia even though my blood tests were normal.  Does this sound like ocular myasthenia?  Or just a damaged tendon?  I should also add that levator function is fine.  When I tilt my head down and look up, my eyelid looks normal.  Is there any other reason this could be happening?

[J0611]

Thank you!

[Dr Sharma]

Hi there. Ocular MG is a disease of the neuromuscular junction resulting in muscle weakness and fatigability. This is an autoimmune disease where anomalous antibodies are produced against the acetylcholine receptors in voluntary muscles. The most common presentation is double vision and eyelid drooping or ptosis wherea the pupil is spared. Diplopia is seen when MG affects a single extraocular muscle in one eye, limiting eye movement and leading to double vision. Ptosis occurs when levator palpebrae is affected on one or both sides. the features of ptosis associated with MG are asymmetric, worsens with fatigue, sustained up gaze and at the end of the day and gaze evoked nystagmus, and Cogan’s lid twitch where upper lid twitch is present when you look straight ahead after looking down for 10-15 secs. Consult with your neurologist in detail with these speculations. Take care.