Abstract
Ocular myasthenia in Graves' disease is very rare with less than 10 cases reported. We present a clinically euthyroid lady with features of thyroid-associated ophthalmopathy (TAO) who had mild ptosis, external ophthalmoplegia, firm goiter and subclinical hyperthyroidism. Hertel exophthalmometry confirmed exophthalmos. CT orbit revealed thickening of bilateral inferior, medial and superior recti. Anti-thyroid peroxidase antibody was positive (154 IU/ml; normal <40 IU/ml). Repetitive nerve stimulation test of bilateral nasalis muscle showed decremental response, more prominent on the left side. Electrodiagnostic screening for concomitant myopathy or neuropathy was unremarkable. A subsequent positive neostigmine test and a positive anti-acetylcholine receptor antibody (1.46 nmol/L; normal <0.5 nmol/L) lead to the diagnosis of ocular myasthenia with TAO and subclinical Graves' disease. Ptosis and ophthalmoplegia improved with pyridostigmine and carbimazole. She was doing well even after 2 years of follow-up. Any patient of TAO with ptosis and ophthalmoplegia should be evaluated for ocular myasthenia. This case intends to highlight that TAO and ocular myasthenia can coexist, is a diagnostic challenge, with important consequences, as lack of treatment of Graves' disease can aggravate myasthenia.
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