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Ptosis in Myasthenia Gravis

Sandeep Dhanyamraju MD
Medically reviewed by Sandeep Dhanyamraju
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Sandeep Dhanyamraju MD
Medically reviewed by Sandeep Dhanyamraju

Myasthenia gravis ptosis is a condition in which the upper eyelid drops, causing the pupil to close and vision impairment.

Usually, the edge of the upper eyelid covers the iris of the eye by about 1.5 mm. If the eyelid drops below the upper edge of the iris by more than 2 mm, this indicates the presence of ptosis in myasthenia gravis. This pathology requires surgical intervention. Without surgery, the disease leads to decreased vision and the appearance of other ophthalmic diseases.

Ocular myasthenia may be present at birth (congenital ptosis) or develop as a result of aging, trauma, or the effects of cataract surgery or other corrective eye surgery.

This condition can also be caused by a problem with the levator muscles that lift the eyelid. Sometimes such difficulties are caused by individual anatomical features.

An eye tumor, a neurological disorder, or a systemic disorder such as diabetes can also cause drooping of the eyelids.

Symptoms can be mild or severe. The degree of weakness in the eye muscles may differ from day to day. The disease symptoms increase in the evening or after prolonged work that requires eye muscle tension. Many people with ocular myasthenia gravis find that their vision temporarily improves after minimal rest by closing their eyes for a few minutes. In the ocular form, there is usually no weakness in the muscles of the limb, and there are no problems with swallowing, speaking, and breathing.

Causes and Symptoms of Myasthenia Gravis 

The main causes of pathology:

  • congenital disease, which is associated with insufficient development of the muscle designed to lift the upper eyelid;
  • injury to the muscle that lifts the upper eyelid;
  • damage to the oculomotor nerve;
  • stretching of the tendon muscle that lifts the upper eyelid (typical for the elderly);
  • the defeat of the cervical sympathetic plexus (the so-called Horner’s syndrome, expressed in ocular myasthenia, constriction of the pupil, and “retraction” of the eyeball);
  • diabetes mellitus as a cause of metabolic muscle and nerve damage;
  • acute violation of cerebral circulation (drooping of the eyelid is accompanied by several other symptoms);
  • a tumor of the brain, spinal cord, or neck area;
  • violation of neuromuscular transmission (myasthenia gravis or myasthenic syndrome);
  • damage to the oculomotor nerve in the framework of polyneuropathy (in combination with damage to many other peripheral nerves);
  • a complication of the introduction of botulinum toxin for cosmetic or medicinal purposes;
  • botulism.

 Why are the muscles of the eyes most often affected in myasthenia gravis?

There are several opinions as to why the eye muscles are most often involved in the disease. However, there is still no exact proof and explanation. 

  1. One hypothesis is that patients are more likely to notice weakness in the eye muscles than slight weakness in the muscles of the limbs.
  2. Another suggests that the muscles of the eyes and eyelids differ in structure from the muscles of the trunk and limbs. 
  3. The muscles of the eyes contain much fewer acetylcholine receptors. 
  4. The eye muscles contract much faster and more frequently, which may be the reason for the quicker fatigue. 
  5. The crucial difference between the muscles of the eyes and eyelids compared to other muscles in the body is the atypical response to an immune attack. 

For this reason, the eye muscles are most often affected by other autoimmune diseases, such as the thyroid gland.

The first symptoms of the disease are:

  • Double vision and drooping of the eyelids are often the first symptoms of MG. 
  • Despite most patients having vision problems at the onset of the disease, many develop muscle weakness, implying a generalized form of myasthenia gravis; this usually occurs within the first two years after diagnosis. Approximately one of 6-7 patients (15%) develops an ocular form of MG. 
  • In half of the patients, generalized muscle weakness develops during the first year of the disease. With an ocular form that lasts more than 5 years, muscle weakness may be absent. It is impossible to predict the development of the form of MG.

Common symptoms of the disease are:

  • partial or complete drooping of the edge of the upper eyelid, which leads to a deterioration in the quality of vision and headaches;
  • throwing the head back to facilitate opening the eye;
  • decreased visual acuity, the appearance of strabismus;
  • constant eye fatigue;
  • bifurcation of objects before the eyes.

Myasthenia gravis diagnosis

Neurological Diseases Leading to Ptosis

Such diseases can lead to ptosis if they are not treated:

  • Myasthenia gravis is a serious disease in which impulse transmission from the nerve to the muscle is impaired. This disease is characterized by increased muscle fatigue. The disease affects all muscles, but the most significant manifestations can only affect the eye muscles, causing ptosis, double vision, and decreased focus. For the primary myasthenia gravis diagnosis, a neurologist conducts a test with the introduction of proserin and examines the nerves and muscles using ENMG (electroneuromyography).
  • In myopathy, double vision is also observed, omission of both eyelids, while the performance of the muscle that lifts the eyelid is weakened but present. The examination uses a needle EMG and some laboratory tests.
  • Palpebromandibular synkinesis – involuntary friendly movements accompanying chewing, abduction, and opening of the lower jaw. For example, when the mouth is open, the prolapse can abruptly disappear, and after closing the mouth, it can recover. This condition can be both a common disease and the result of improper restoration of the motor fibers of the facial nerve after its defeat.
  • Bernard-Horner syndrome (expressed by a combination of drooping of the upper eyelid, constriction of the pupil, and “retraction” of the eyeball). It is a manifestation of the pathology of the cervical sympathetic plexus. Sometimes pathology is found due to increased sweating on the face and incomplete paralysis of the brachial nerves on the diseased side.

Myasthenia Gravis Diagnosis and Treatment

Myasthenia gravis diagnosis

  • Upper eyelid ptosis cannot be prevented, but you can get it diagnosed early. 
  • You should start treatment before the field of vision is significantly limited and the cosmetic defect becomes noticeable.

Examination of the patient by an ophthalmologist for ocular myasthenia includes:

  • Collecting anamnesis for a more accurate diagnosis of the cause of the disease;
  • Measuring the width of the palpebral fissure (the distance between the edges of the upper and lower eyelids);
  • Examination of the fundus to assess visual acuity;
  • Biomicroscopy to determine the condition of the tear film, cornea, and conjunctiva.

To exclude cysts and tumors of the accessory apparatus of the eye and brain, the following instrumental studies can be carried out:

  • Ultrasound of the accessory apparatus of the eye and orbit;
  • MRI of the brain with the study of blood flow;
  • CT scan of the brain;
  • CT of orbits.


Treatment depends on the causes:

  1. If the cause of the drooping of the eyelid is a neurological disease, such as myasthenia gravis or neuropathy, then, first of all, therapy of the underlying disease is carried out. Since ptosis is a symptom, it goes away after the underlying disease is cured.
  2. In some cases, full recovery is impossible, so surgical treatment is carried out for cosmetic therapeutic purposes if ocular myasthenia leads to significant disruption of life due to deterioration of vision.
  3. For children, such an operation is performed upon reaching the age of 3. But this should be done as soon as possible to prevent a decrease in vision and the development of strabismus.
  4. The operation is recommended after puberty to eliminate a cosmetic defect (when vision is not impaired) when the facial bone skeleton is finally formed.
  5. If the prolapse is caused by trauma, the operation can be performed directly during the initial treatment of the wound surface by the surgeon or after healing (6-12 months).

The doctor decides on the timing of the operation depending on the specific case.

Descent of the eyelid after the introduction of botulinum toxin

According to statistics, after injecting botulinum toxin (“Botox” and other preparations containing it) in the eye area, a drooping eyelid occurs in 20% of complicated cases, but this is almost always due to errors during the procedure or to an individual characteristic of a person.

The drooping of the eyelid after the introduction of Botox is unpleasant. But it cannot be considered a serious pathology since without additional therapy, the signs of drooping completely disappear within 3-4 weeks after the injection of the drug.

Prevention of Ocular Myasthenia

Prevention of the Development of Ocular Myasthenia  

Timely treatment of any diseases that can provoke this pathology is important in preventing prolapse of the eyelid. 

  • For example, neuritis of the facial nerves must be treated immediately by a neurologist, and the possibility of drooping of the eyelids after Botox injections should be discussed with the specialist performing the manipulation.
  • If you notice the weakness of the eyelids associated with age-related changes, then cosmetic and folk remedies can help you. Prevention methods include the use of tightening masks, oils, and massage treatments.
  • You should massage the skin of the eyelids when drooping. Before the procedure, you can wipe the eyelids with lotion to remove the sebaceous scales and open the excretory ducts of the sebaceous glands. Massage with a cotton swab or disc soaked in an antiseptic solution or special ointment; use light pressure stroking in a circular and straight motion, moving from the inner corner of the eye to the outer corner. You can tap your eyelids lightly with your fingertips.
  • There is a special gymnastics for the weakness of the eye muscles to prevent ocular myasthenia.

 Special Gymnastics to Prevent Ocular Myasthenia Gravis

Starting position: standing, sitting, or lying down.

  1. Look up without raising your head, then sharply down. Repeat the movements 6-8 times.
  2. Look up and to the right, then diagonally down and to the left. Repeat the movements 6-8 times.
  3. Look up and to the left, then down and to the right. Repeat the movements 6-8 times.
  4. Look as far as possible to the left, then to the right. Repeat the movements 6-8 times.
  5. Stretch your hand forward- keep it straight. Look at the tip of your index finger and gradually bring it closer, without stopping to look until the picture begins to “double”. Repeat the movements 6-8 times.
  6. Place your index finger on the bridge of your nose. Move your gaze to your finger alternately with your right and left eyes. Repeat 10-12 times.
  7. Move your eyes in a circle to the right and left. Repeat the movements 6-8 times.
  8. Blink quickly for 15 seconds. Repeat blinking up to 4 times.
  9. Close your eyes tightly for 5 seconds, then sharply open your eyes also for 5 seconds. Repeat 10 times.
  10. Close your eyes and massage your eyelids with your finger in a circle for 1 minute.
  11. Move your gaze from the nearest point to the far one and vice versa.
  12. The movement of the eyeball during exercise should be as wide as possible but so that it does not hurt you. The motor pace can be complicated over time. The duration of such prophylaxis is at least 3 months.

In the case of myasthenia gravis and myopathy, such exercises are contraindicated, as they contribute to the aggravation of the drooping of the eyelid due to “exhaustion” of the muscle. Therefore, before engaging in any method of treatment, it is necessary to consult a specialist.


  • What disease causes partial or complete drooping of the edge of the upper eyelid, constant eye fatigue and bifurcation of objects in front of the eyes?

Myasthenia gravis ptosis is a condition in which the upper eyelid drops, causing the pupil to close and vision impairment. 

  • What is abduction nystagmus?

Abduction nystagmus is a dissociated, acquired form of jerky nystagmus with an abductive fast phase and a slow phase directed towards the midline. Usually occurs when the eye moves towards the temple, while the other eye remains motionless in the primary position. 

  • Can Congenital Ptosis Be Cured?

Treatment of ptosis of the upper eyelid should be started immediately in order to avoid the development of complications (decreased visual acuity – amblyopia, strabismus, forced head position). It is important to note that ptosis usually does not go away without treatment; today, surgical treatment of this condition is accepted.

  • How is the ptosis of the upper eyelid operated on?

If the functions of the muscle that lifts the upper eyelid are slightly impaired, an operation is performed to shorten it. In this case, the doctor makes an incision in the skin, selects the desired area of ​​muscle tissue, shortens it, and fixes it on the cartilage of the upper eyelid. Then a palpebral fold is formed.

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Edward Medina
Edward Medina
15:34 30 Jun 22
Just such an amazing staff that makes you feel like part of their family. I’ve been going there for over 5 years now... and each visit I get the very best care and treatments that I have ever received in the 20+ years that I’ve been dealing with severe debilitating migraines. Since i started seeing them the number of my migraines has dropped from 15-20 a month to 2-3 every 3 month. I highly recommend them …they will change your life!read more
Daneisha Johnson
Daneisha Johnson
22:20 19 May 22
Dr. Askari was very kind and explained everything so I could understand. The other staff were nice as well. I would... have gave 5 stars but I was a little taken aback when I checked in and had to pay 600.00 upfront. I think that should have been discussed in a appointment confirmation call or email just so I could have been more
Jean Cooper
Jean Cooper
16:54 29 Apr 22
I love the office staff they are friendly and very helpful. Dr. JODIE is very caring and understanding to your needs... and wants to help you. I will go back. would recommend Dr. Dr. Jodie to other Patients in a heart beat. The team works well more
Linda M
Linda M
19:40 02 Apr 22
I was obviously stressed, needing to see a neurologist. The staff was so patient and Dr. Ansari was so kind. At one... point he told me to relax, we have time, when I was relaying my history of my condition. That helped ease my stress. I have seen 3 other neurologists and he was the only one who performed any assessment tests on my cognitive and physical skills. At one point I couldn't complete two assessments and got upset and cried. I was told, it's OK. That's why you're here. I was truly impressed, and super pleased with the whole experience!read more
Leslie Durham
Leslie Durham
15:05 01 Apr 22
I've been coming here for about 5 years. The staff are ALWAYS friendly and knowledgeable. The Doctors are the absolute... best!! Jodie Moore is always in such a great mood which is a plus when you are already stressed. Highly recommendedread more
Monica Del Bosque
Monica Del Bosque
14:13 25 Mar 22
Since my first post my thoughts have changed here. It's unfortunate. My doctor and PA were great, but the office staff... is horrible. They never call you back when they say they will, they misinform you, they cause you too much stress wondering what's going on, they don't keep you posted. They never answer the phone. At this point I've left four messages in the last week, and I have sent three messages. Twice from their portal and one direct email. No response. My appointment is on Monday morning at 8:30am, no confirmation on my insurance and what's going on. What the heck is going on, this is ridiculous!I've given up... the stress her office staff has put me through is just not worth it. You can do so much better, please clean house, either change out your office staff, or find a way for them to be more efficient please. You have to do something. This is not how you want to run your practice. It leaves a very bad impression on your more
Ron Buckholz
Ron Buckholz
23:32 23 Mar 22
I was actually pleasantly surprised with this visit! It took me a long time to get the appointment scheduled because no... one answers your phones EVER! After a month, I finally got in, and your staff was warm, friendly, and I was totally impressed! I feel like you will take care of my needs!read more
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Steve Nabavi
16:28 16 Mar 22
It was a nice visit. Happy staff doing all they can do to comfort the patients in a very calming environment. You ask... me they are earned a big gold star on the fridge. My only complaint they didn't give me any more
Katie Lewis
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16:10 10 Feb 22
Had very positive appointments with Jodie and Dr. Sheth for my migraine care. Jodie was so fast with the injections and... has so much valuable info. I started to feel light headed during checkout and the staff was SO helpful—giving me a chair, water, and taking me into a private room until I felt better. Highly recommend this practice for migraine patients, they know what they’re doing!!read more
Joshua Martinez
Joshua Martinez
16:02 10 Dec 21
I was scheduled to be checked and just want to say that the staff was fantastic. They were kind and helpful. I was... asked many questions related to what was going on and not once did I feel as though I was being brushed off. The front desk staff was especially great in assisting me. I'm scheduled to go back for a mri and am glad that I'll be going more
Isabel Ivy
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21:42 03 Nov 21
I had such a good experience with Lone Star Neurology, Brent my MRI Tech was so awesome and made sure I was very... comfortable during the appointment. He gave me ear plugs, a pillow, leg support and blanket, easiest MRI ever lol 🤣 My 72 hour EEG nurse Amanda was also so awesome. She made sure I was take care of over the 3 days and took her time with the electrodes to make sure it was comfortable for me! Paige was also a huge help in answering all my questions when it came to my test results, and letting me know her honest opinions about how I should go forth with my more
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Leslie Luce
17:37 20 Oct 21
The professionalism and want to help attitude of this office was present from the moment I contacted them. The follow... up and follow through as well as their willingness to find a way to schedule my dad was above and beyond. We visited two offices in the same day with the same experience. I am appreciative of this—we spend a lot of time with doctors and this was top notch start to more
robert Parker
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16:38 16 Apr 21
I love going to this office. The staff is friendly and helpful. The doctor is great. I am getting the best... neurological tests and treatment I have ever had. The only reason I did not give them a 5 star rating is because it is impossible to reach a live person at the office to reschedule appointments. Every time I have tried to get through to the office it says all people are busy and I am sent to a voicemail. If they could get their phone answering fixed, I would give them a strong 5 more
MaryAnn Hornbaker
MaryAnn Hornbaker
00:26 25 Feb 21
Dr. Harney is an excellent Dr. I found him friendly , personable and thorough. I evidently am an unusual case. ... Therefore he spent a Hugh amount of time educating me. He even gave me literature to further explain my condition and how to follow up. This is something you rarely get from your doctors. So I am more than please with my doctor and his more
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Roger Arguello
03:05 29 Jan 21
Always courteous, professional. The staff is very friendly and always work with you to find the best appointment time.... The care team has been great. Always taking the time to listen to your concerns and to find the best more
Margaret Rowland
Margaret Rowland
01:12 27 Jan 21
I have been a patient at Lone Star Neurology for several years. Now both my adult daughters also are patients there. I... love Jodie. She is always so prompt whether it is a teleamed call are a visit in the office. She takes the time to explain everything to me and answers all my questions. I am so blessed to have Jodie as my more
Susan Miller
Susan Miller
03:01 13 Jan 21
My husband had an accident 5 years ago and Lone Star Neurology has been such a blessing to us with my husbands care.... Jodie Moore is his provider and she is amazing! Jodie is very knowledgeable, caring, and thorough. She takes her time with you, making sure your needs are met and she is happy to answer any questions you may have. Lone Star Neurology’s patients are very lucky to have Jodie providing their care. Thank you Lone Star Neurology and especially Jodie for everything you have done for us. Jodie, you are the best!read more
Windalyn C
Windalyn C
01:32 09 Jan 21
Jodie is wonderful. She is very caring and knowledgeable. I have been to over a dozen neurologists, and none were able... to help me as much as they have here. Thanks!read more
Katie Kordel
Katie Kordel
00:40 09 Jan 21
Jodi Moore, nurse practitioner, is amazing. I have suffered from frequent, debilitating headaches for almost 20 years.... She has provided the best proactive and responsive care I have ever received. My quality of life has been greatly improved by her caring approach and tenacity in finding more
Ellie Natsis
Ellie Natsis
15:41 07 Jan 21
I have had the best experience at this neurologist's office! For over a year I have been receiving iv treatments here... each month and my nurse, Bobbie is beyond wonderful!! She's so attentive, knowledgeable, caring, and detail oriented. She makes an otherwise uncomfortable experience much more pleasant and definitely puts me at ease! She also helps me with my insurance,ordering this specialty medication and dealing with the ordering process which is no easy feat.Needless to say, she goes above a beyond in every way and I'm so grateful to this office and to Bobbie for all they do for me!read more
Matt Morris
Matt Morris
15:39 07 Jan 21
Let me start by saying that I have been coming here for years. Due to my autoimmune disease, I am in this office... once every three weeks for multiple hours at a time. The office is very clean and the staff very friendly. My only complaint would be there communication via phone. They aren't the best at responding if you leave a voicemail and expect a call back. I understand that this is prob just due to the sheer number of alls they receive daily. What I can say I like the best about the office are the people. Bobby who handles my infusions is great. I never have any issues with her setting up my infusions. She is very quick to reply to messages sent via text and if she were to leave then my whole opinion of the office may change. I also enjoy people like Matt, Lauren, and Jodi. I appreciate all that they do for me and without this team I'm not sure I would be as happy as I am to visit the office as frequently as I have to. Please ensure that these folks are recognized as they are what makes my visit to this office so tolerable :).read more
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