Myasthenia gravis explained: The case of woman’s left eye becoming smaller in the evenings

The neurologist suspected that she has myasthenia gravis, also known as myasthenia, a neurological disorder that weakens the voluntary muscles — the muscles that one could control.

The neurologist prescribed her a thorough investigation. Dr Kumar, who tweets interesting medical case studies almost daily, wrote about the incident on Tuesday, 29 November.

#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

— Dr Sudhir Kumar MD DM🇮🇳 (@hyderabaddoctor) November 29, 2022

Curious case of asymmetrical eyes

“The woman accompanied her husband, who had suffered a stroke recently,” Dr Kumar told South First. “After noticing her left eyelid, I enquired if it drooped throughout the day,” he added.

Dr Sudhir Kumar, Neurologist. (Supplied)

She said it would be normal in the morning but hangs later.

“It was a classic example. The eyelid’s muscles get fatigued as the day progress. They will be energetic in the mornings after a good night’s rest,” he said.

The doctor said the woman had no other problem with the eyes except for one eye looking smaller for the past four to five months.

Dr Sudhir explained that blocked links between the nerves and muscles lead to myasthenia gravis.

The woman underwent a thorough investigation, which confirmed the neurologist’s diagnosis.

“Investigations found her repetitive nerve stimulation to be normal but acetylcholine receptor antibody was high,” he said.

Types of myasthenia gravis

Myasthenia gravis are of two types: Ocular and generalised. Ocular myasthenia gravis can affect one eye or both, causing a drooping eyelid or double vision. If not treated, it can progress into generalised myasthenia gravis, affecting all muscles in the body.

“It can cause clumsiness, trouble speaking, eating, or swallowing. It can also lead to frequent falls. In some cases it can affect throat and tongue muscles that help the airway from the nose and mouth to the lungs,” Dr Prabhudeva G, a Bengaluru-based neurologist, said.

Amitabh Bachchan and myasthenia gravis

The Hyderabad woman, now Dr Kumar’s patient, is responding well to the treatment.

She was a bit troubled after the doctor’s diagnosis was confirmed. Dr Kumar explained her that actor Amitabh Bachchan, too, was diagnosed with the same condition in 1984.

He tweeted, “….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,”

The doctor said the eyes of 25 percent of the population have a mild asymmetry (1mm or more). But, eyes becoming smaller in evenings or having double vision could be signs of myasthenia gravis.

“Amitabh Bachchan is a fighter. If you notice closely, his eyelids droop slightly in the evenings. However, he is undergoing treatment and is doing good,” he said.

Also read: Doctors remove 150 larvae from woman’s nose and eyes 

Heat can worsen the condition

Dr Kumar explained that most patients have difficulty in swallowing, speaking, chewing food, weakness of arms or legs and difficulty in breathing in severe cases.

The symptoms get more visible in the evenings and with repeated muscle activity. Myasthenia gravis is an auto-immune disease, affecting the junction of nerve and muscles,” he explained.

Heat, stress, infections, surgeries, certain drugs, menstruation, and pregnancy could worsen the symptoms, besides during postpartum period. The doctor added that the diagnosis is by up to five years in 13 percent of the patients.

Early diagnosis

Myasthenia gravis is treatable, if diagnosed early. Early diagnosis and prompt treatment give excellent results. It also prevents severe symptoms like difficulty in breathing.

“Normal treatment suffices in most cases. In some cases, thymectomy (removal of the thymus gland) is needed,” Dr Kumar said.

He added that asymmetrical eyes or varying eye size at different times of the day could be a sign of myasthenia gravis.