Synopsis
Recognise fluctuating ocular weakness, investigate suspected myasthenia, identify generalisation, and apply current specialist-guided UK treatment principles.
- Ocular myasthenia commonly causes fluctuating ptosis and binocular diplopia that worsen with sustained use and improve with rest.
- Pupils, sensation and visual acuity are usually unaffected; pain, a pupil abnormality or true visual loss warrants investigation for another or additional disorder.
- A negative antibody test does not exclude ocular myasthenia; specialist neurophysiology may be required.
Key red flags
New breathing difficulty, choking, weak cough or inability to manage secretions in suspected myasthenia requires immediate hospital assessment.
Investigation priorities
Establish the pattern and detect bulbar or respiratory compromise requiring hospital care.
Management branches
An ocular presentation is accompanied by significant swallowing, breathing or rapidly progressive generalised weakness.
- Arrange immediate hospital assessment and communicate the suspected neuromuscular diagnosis and current medicines.
- Assess airway protection, ventilation and swallowing, involving neurology and critical care early when deterioration is significant.
Fluctuating ptosis or binocular diplopia suggests neuromuscular junction dysfunction without emergency features.
Key medicines
Pyridostigmine for ocular symptomsABN 2025 starts 30 mg orally three or four times daily with gradual clinician-directed titration; if needed, treatment may reach 60 mg four times daily over five to ten days. Up to 360 mg daily in divided doses may be used, but requirements above 300 mg daily prompt early specialist review.
Daily prednisolone for ocular myastheniaABN 2025 starts 5–10 mg orally daily, increasing by 5 mg every three to five days according to response towards an initial ocular target of 20 mg daily. Further specialist titration may reach 0.5 mg/kg daily, capped at 30 mg daily; subsequent maintenance and taper follow disease control.