Thread by @hyderabaddoctor

#eyes becoming smaller in evenings could be a sign of #neurological illness

1. I was seeing the last patient, on what had been a busy Monday. While counselling the patient's attendant (aged 45), I noticed that her left eye was smaller than the right.

#MedTwitter #neurotwitter

2. On enquiry, she confirmed that her eyes were of equal size in mornings, but left eye became smaller as the day progressed. This was the case for the past 4-5 months. She had no other issues. This had been noted by her family members and friends too. An eye check up was normal.

3. I discussed with her that this could be a sign of #myasthenia gravis (MG) and asked for investigations. Repetitive nerve stimulation was normal. However, acetylcholine receptor antibody was high (8; normal value<0.25). The diagnosis of MG was confirmed. CT chest was normal.

4. She was started on appropriate medical treatment, and she responded well.
She was anxious about her illness. I mentioned that @SrBachchan too had MG, diagnosed in 1984 and his life story is an encouragement for all patients living with this disease.
#Neurology

5. Mild asymmetry (1 mm or more) in eye size can be normally seen in about 25% of people. However, eyes becoming smaller in evenings or associated with double vision can be a sign of MG. MG affects only eyes in about 20% of patients. Other symptoms are difficulty in swallowing +

6. difficulty in speaking, chewing food, weakness of arms or legs and breathing difficulty in severe cases. Symptoms get worse in evenings and with repeated muscle activity. MG is an auto-immune disease, affecting the junction of nerve and muscles.

7. Symptoms of MG can also get worse with heat, stress, infections, surgery, certain drugs, menstruation, pregnancy and in post-partum period. The diagnosis may get delayed by up to 5 years in about 13% of patients.

8. Early diagnosis and prompt treatment results in excellent outcome and also prevents myasthenic crisis (severe symptoms such as difficulty in swallowing and breathing difficulty).
Medical treatment suffices in most cases, in some, thymectomy (removal of thymus gland) is needed

9. Take home message
Asymmetry in eye size (palpebral fissure height) between the two eyes or variation in eye size at different times of day can be a sign of myasthenia gravis.
Early diagnosis and treatment of MG can prevent hardships for the sufferer.