Alternating IV Nerve Palsy and Ptosis as a First Sign of Childhood Ocular Myasthenia Gravis

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A previously healthy 5-year-old girl was referred because of sudden-onset diplopia. Her examination demonstrated moderate right ptosis, left inferior oblique overaction and superior oblique underaction, and a positive Bielschowsky head tilt test to the left. This suggested a left fourth nerve palsy, but the right ptosis remained undefined (Figure). Ophthalmic and neurological examination and cranial magnetic resonance imaging were otherwise normal. Ten days later, a right fourth nerve palsy with a right ptosis and left adduction deficit was evident.