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Myasthenia gravis is one of the most missed diagnoses in ophthalmology. This is not for lack of characteristic signs and symptoms nor for lack of available diagnostic tests, but simply for lack of suspicion on the part of the ophthalmologist and because of an ophthalmological penchant for the too liberal use of "oculomotor palsy" to label all ptoses. That ophthalmologists should be ever aware of the disease follows from the fact that half or more of myasthenic patients present themselves first to the ophthalmologist because of ptosis and ophthalmoplegia. The characteristic symptoms are a drooping of the lid and a diplopia that are minimal in the morning, worsened by fatigue, subject to spontaneous remissions, and dramatically improved by intramuscular injection of prostigmine or intravenous injection of edrophonium chloride (Tensilon).
Behind these very practical considerations is a disease with theoretical implications that have fascinated pharmacologists, physiologists, and physicians for decades. Some
C. DG. Current Concepts of Myasthenia Gravis. Arch Ophthalmol. 1965;74(1):1-3. doi:10.1001/archopht.1965.00970040003001