Management of Fatigue and Nystagmus in Myasthenia Gravis

First-Line Treatment

• Pyridostigmine bromide administered orally two to four times a day is the first-line treatment for fatigue and ocular symptoms in myasthenia gravis, though about half of patients with strabismus-associated myasthenia show minimal response 1, 2
• Acetylcholinesterase inhibitors, such as Pyridostigmine (60mg orally 2-4 times daily), are the initial symptomatic treatment for fatigue and ocular manifestations including nystagmus 1, 2

Second-Line Treatment

• Corticosteroids should be added if pyridostigmine provides inadequate relief, with 66-85% of patients showing positive response 1, 2

Third-Line/Adjunctive Treatments

• Immunosuppressive therapy, such as azathioprine, can be considered for patients with inadequate response to corticosteroids or those who need steroid-sparing agents 1
• Newer targeted therapies, such as Efgartigimod alfa-fcab, can be considered for refractory cases 1

Management of Persistent Ocular Symptoms

• Ocular symptoms like nystagmus and diplopia are highly variable and often not readily remedied with prisms 1
• Application of ice pack over closed eyes for 5 minutes may temporarily reduce misalignment 3, 2

Surgical Options

• Thymectomy can be considered in patients with thymoma or in certain subpopulations with generalized MG to reduce symptoms 1
• Strabismus surgery may be considered after disease stabilization (typically 2-3 years of treatment) if diplopia persists and is not manageable with prisms 1, 2

Multidisciplinary Approach

• Management requires collaboration between ophthalmologist and neurologist 1, 3

Special Considerations

• Monitoring for generalization is crucial, and signs of respiratory distress that might indicate generalization of the disease should be vigilantly watched for 1, 3
• Inadequate monitoring can lead to failure to regularly assess for disease progression from ocular to generalized MG 3