Enhanced Ptosis in Myasthenia Gravis

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Abstract
The ocular manifestations of myasthenia gravis result from a dysfunction at the myoneural junction. Histories of diurnal variation, exacerbation during fatigue, periodic remission, and responsiveness to edrophonium chloride (Tensilon) are characteristic.1Common signs are asymmetrical ptosis and ophthalmoplegia. Less common findings are lid retraction and lid oscillations.2Abnormal saccadic movements,3-6gaze palsies, vertical nystagmus,7lid twitch, and pseudointernuclear ophthalmoplegia8have also been reported. The question of pupillary dysfunction has not been fully resolved."This article describes "enhanced" ptosis as an unusual manifestation of ocular myasthenia gravis and discusses possible mechanisms. TECHNIQUE "Enhanced" ptosis is demonstrated during ocular upgaze in patients with bilateral ptosis by elevating and maintaining the more ptotic eyelid in a fixed position (Figure). The opposite eyelid slowly falls and may close completely. In this latter state, eyelid tone is greatly reduced. A variation of this response has also been observed; in

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