AnnK
150 posts
May 23, 2010
5:14 AM
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I was wondering whether OMG is always 'pupil sparing', i.e. the MG weakness never effects the ability of the iris to expand and contract? (Apologies if I am not using the correct terminology to describe what I am talking about, but I hope you will get my meaning).
I ask the above because I have read somewhere that OMG never effects the muscles actually in the eye, but only the extra-ocular muscles and the other muscles surrounding the eye and the lids. However, although I have been diagnosed as having OMG, I have noticed that the eye that I don't patch gives me blurry vision, i.e. by late afternoon or early evening, and when I'm particularly tired, even earlier. I'm wondering whether the blurriness (slight double vision) could be caused by my extra-ocular muscles tiring and not allowing my eye to focus through the 'sweet spot' of my specs or whether the MG is affecting my ability to focus for other reasons. (NB When I make sure that all of the light is blocked out of my patched eye this makes no improvement to the blurriness - I wondered whether the slight double vision was because I was still seeing some images with my patched eye, but it isn't the case and therefore not the reason for the blurriness.)
When I rest and cool my eyes the blurriness improves a bit and I can once again get fairly sharp vision through my specs, but usually not for all that long. (It feels as though I need one pair of prescription specs for the mornings and another pair of different prescription specs for the afternoons/evenings!)
Thanks in anticipation of any responses to this query.
Ann
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Levitas
1219 posts
May 23, 2010
8:07 AM
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MG affects only skeletal muscles. (Voluntary Muscles you can control at will).
The iris sphincter is a "smooth" muscle.
Perhaps it's as well that MG does not affect sphincters!
However Mestinon can and does affect smooth muscle including the iris.
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Levitas
Last Edited on 23-May-2010 8:23 AM
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AnnK
151 posts
May 23, 2010
8:46 AM
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Hi Levitas
That's what I thought too. But during a bit of surfing this afternoon, after I'd written on the forum, I found this article: http://www.medscape.com/viewarticle/410859_3 about 'the ocular aspects of myasthenia gravis: clinical ocular signs' - see last paragraph headed 'Pupil and Accommodation'. Just my luck to probably have an eye symptom that is rare in MG! I will, of course, ask my neurologist about this when I next see him in 3 months' time.
I'm not on Mestinon at the moment as it only helps my ptosis and I had noticed that my better eye was more blurry when taking it - but had thought that the latter was my just my imagination at the time.
If I don't have one of the rare symptoms of my pupil being involved, is it possible to get blurry vision just because of the extra-ocular muscles becoming fatigued and not allowing one to see through the 'sweet spot', so to speak, of one's prescription specs, do you know?
Many thanks
Ann
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JohnnyG
423 posts
May 23, 2010
12:30 PM
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Ann,
I can confirm that my eyes definitely have a little trouble 'accommodating'. By that I mean that when do things like switching from looking at something close to more distant it takes a bit longer than healthy eyes to make the adjustment -- and this gets more noticeable as I get tired.
It is interesting you describe the vision with one eye as "slight double vision" -- it shouldn't really be possible to get double vision with one eye -- more likely that the image is just a bit blurry?
I just had my eyes tested the other day and had a good discussion with the optician. I'm at the age where I need vari-focal lenses so I can see near and far. We decided to make the lenses a bit stronger at both ends of the range so that they can make up the difference when my eyes get tired. I'll let you know how the new lenses work out.
Incidentally, the eyes being slow to accommodate was very noticeable in the eye test, where you get the "is this image clearer or this one?". If they don't leave them there a while they both look blurry.
In other news, the optician reported my eyes are showing the beginnings of cataracts -- given my age this is likely down to the pred. On the plus side, I'm told when they do the cataract treatments these days they true up your lenses while they are at it, so not all bad news.
Many MG sufferers report being intolerant of bright light too (I'm in this category). I'd assumed this meant the pupil does not adjust as well -- but now I'm confused as the suggestion is the pupil muscles aren't the sort MG affects.
John
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Ottawa, Canada
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ilcraque
33 posts
May 23, 2010
2:18 PM
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ok, some clarifications;
1. MG affects skeletal muscles AND extraocular muscles (the latter being rather distinct from skeletal ones)
2. the muscle that does the accommodation work is called ciliary muscle and the pupil muscles are indeed sphincter pupillae and dilator pupillae.
3. blurred vision can be due to accommodation deficit (ciliary muscle) or slight double vision. (both atributed to fatigue). MG can affect ciliary muscle / accommodation.
4. in fact, blurred vision is rather straightforward and common symptom among MG patients.
5. if indeed there is pupil involvement- like let's say that the size of pupils differ considerably, one might suspect other diagnosis (especially if there is pain involved).
best;
tom
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http://ocular-myasthenia.blogspot.com/
Last Edited on 23-May-2010 2:23 PM
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Barbara82
21 posts
May 23, 2010
3:15 PM
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I have just had a cataract operation. The op itself was a success but afterwards retinal vein occlusions were fornd which is affecting my sight. The pupil of that eye has been dilated since the op which is a mystery to the Consultant (not a neurologist)There is no pain involved.
Barbara
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AnnK
153 posts
May 24, 2010
10:24 AM
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Hi John (JohnnyG)
Many thanks for your response - I would indeed be very interested to hear how you get on with your new lenses that are stronger at both ends of the range, especially as I too wear bi-focals - What might work for you might also work for me.
It's true about the lens replacements when you have a cataract op, i.e. they do 'true up the lenses' - My mother had the op and was very pleased with the result.
With regard to the vision in my unpatched eye, I suppose you could call it blurry but I understand that blurry vision can be due to slight double vision - The image I get is of a close overlay of image, e.g. if I am looking at the telly at a newscaster's head I see two outlines of their head very close together but, nevertheless, two outlines. Whereas when I look at the newscaster with both my eyes together they have two distinct heads very wide apart...
I understand that it is possible to have double vision in one eye but for reasons other than MG, but I have had my eyes checked out at the hospital several times and they haven't found anything else wrong...they suspected thyroid eye disease at one point, but have ruled that out now, but I don't think that that would have given me monocular double vision anyway.
Thank you for the tip about being asked "is the image clearer in this one or this one" as part of the eye test - I'll ask the optician to wait a bit longer while my eyes adjust and have a chat like you have done about my accommodation problems. My accommodation troubles are sadly a bit more than needing time to adjust from looking at something close and then at something in the distance and back again...When my eyes are tired in the afternoons and evenings they simply don't adjust and only improve with closing and resting my eyes and cooling them with a cooling eye mask that I put on my eyes for at least half an hour.
Many thanks
Hi Tom
When you say that blurred vision is common in MG - Is that the case only for when you use both eyes or can the blurriness be monocular too, do you know?
Many thanks
Ann
Last Edited on 24-May-2010 10:48 AM
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ilcraque
38 posts
May 24, 2010
3:36 PM
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blurriness can be monocular. (most likely due to fatigued accommodation/ ciliary muscle)
best;
tom
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http://ocular-myasthenia.blogspot.com/
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AnnK
157 posts
May 25, 2010
12:22 PM
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Thanks, Tom.
I suppose that's why my vision improves a bit for while in the evenings after I close my eyes and cool them for about half an hour, i.e. because the blurriness is down to fatigue. I suppose no lens is going to improve the situation, unfortunately.
Ann
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ilcraque
39 posts
May 25, 2010
2:15 PM
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... well, you could try a pair of reading glasses if you notice any difference.
accommodation deficits are usually treated with + lenses. one can actually "take away" all accommodation that the eye is capable by itself (and compensate with prisms). this technique could apply for near work. but if you already have two prescription glasses i see no need of adding another pair (except if the situation it too bothering)...
best;
tom
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http://ocular-myasthenia.blogspot.com/
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Gill87440
6 posts
Jun 27, 2010
12:22 AM
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Hi Anne,
When you are out in the sun, do you get a headache on the same side as your ptosis? Also on occasions I get throbbing nerve pains under the inside of the eyebrow and down the side of the nose.
I am going to see an orthoptist who thinks it may be 3rd Cranial nerve palsy, but then MG mimics that, doesn't it!!
Look forward to your views,
Gill
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AnnK
176 posts
Jun 29, 2010
8:33 AM
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Hi Gill
Yes, I do get a headache on the same side as my ptosis - with a vengeance - in the sunshine. But the bulk of my headaches are associated with my relatively 'good' eye without the major ptosis, i.e. the one that I use all the time, my other eye (the one with the major ptosis) being patched - I believe it is associated with the muscles around my 'good' eye straining to assist my 'bad' patched eye, i.e. the Hering's Law phenomenon. I do also get throbbing nerve pains under the inside of my eyebrow and down the side of my nose, but that again is on the side of my face without the major ptosis...
Are your throbbing nerve pains on the side of your face with the ptosis and only when you are in the sun or at other times, i.e. when you're not in the sun but perhaps later in the day when you've used your muscles more and you're more tired? MG generally can get worse with the heat and, even with sunglasses, you can't help but use your muscles more squinting in the sun and I believe the muscles have to work harder in the heat - more muscle jitter I gather. I've found that it helps to cool and rest the eyes by closing them for a while by applying a cooling eye mask (disposable from Boots). But sometimes the whole of the side of my face feels as though I'm wearing the Phantom of the Opera's mask! - all kind of heavy and uncomfortable whatever I do to try to help myself. I also have a pair of wrap-around over spectacle sunglasses which help quite a lot in the sun but when the weather's very hot they steam up too much! I found the amber coloured ones to be the most restful on my eyes rather than the grey tinted ones. I got them from the RNIB. Mind you, the 'look' isn't very becoming!
I keep wondering about 3rd Cranial nerve palsy too. When I first went to the eye hospital accident and emergency the doctor I saw said that that could be causing my problems, but I assume it has been ruled out in my case. Perhaps I should query this again before I agree to taking steroids and/or immuno-suppressants. Do let me know what your orthoptist says and what s/he suggests can be done to help you.
All the best
Ann
Last Edited on 29-Jun-2010 9:12 AM
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alice
867 posts
Jul 01, 2010
9:52 AM
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someone sent me this video clip which I thought you may find interesting.
http://cancertype.me/new-test-to-diagnose-myasthenia-gravis.html
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AnnK
185 posts
Jul 02, 2010
5:22 AM
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Alice
Watched the video clip and I did indeed find it interesting.
Do you think that this innovation is indicative that there is pupil involvement in OMG (e.g. ciliary muscle weakness) whereas at one time it was thought OMG was always pupil-sparing? I note, however, that the equipment/test is also used to detect small fibre neuropathy which seems to be a generalized disorder - not always involving the eyes(?) - or perhaps I'm wrong about that.
Ann
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alice
868 posts
Jul 02, 2010
8:34 AM
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I am not sure how good this test is. I just found it interesting that a neurologist not only does not say that there is no pupillary involvement in MG, but in fact creates an intvention based on this.
This is based, I believe on a study that was done 30 years ago, but totally ignored.
alice
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AnnK
188 posts
Jul 03, 2010
4:55 AM
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Do you have a reference to the study, e.g. on the net? I'd be interested in seeing it.
Thanks
Ann
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alice
873 posts
Jul 04, 2010
8:16 AM
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Pupillary dysfunction in myasthenia gravis
Frederick E. Lepore, MD, George E. Sanborn, MD, Dr John T. Slevin, MD *
Departments of Neurology and Ophthalmology, University of Virginia School of Medicine, Charlottesville, VA
*Correspondence to John T. Slevin, Department of Pharmacology, The Johns Hopkins University, 725 N Wolfe St, Baltimore, MD 21205
Abstract
The constriction-dilation cycles of pupils exposed to a stationary, discrete slit-lamp beam were significantly prolonged in 25 myasthenic patients (1,060.4 ± 45.8 msec) undergoing therapy with steroids, anticholinesterases, or both, compared to normal controls (801.9 ± 8.6 msec) or subjects receiving steroids for nonneurological disease (860.9 ± 14.9 msec). The duration of myasthenia correlated with the slowing of the cycle time. Myasthenia gravis may affect ectodermally derived smooth muscle or the autonomic neuromuscular junction or both, and not be restricted to the well-demonstrated alterations of neuromuscular junction in striated muscle of mesodermal origin. Alternatively, prolonged pupillary cycles could be attributed to dysfunction of central pathways of the pupillary light reflex.
-------------------------------------------------------------- of Neurology
Volume 6 Issue 1, Pages 29 - 33
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AnnK
192 posts
Jul 04, 2010
11:05 AM
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Thanks Alice.
Ann
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Gill87440
7 posts
Jul 05, 2010
8:32 AM
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Hi Ann,
The nerve pain I get is on the same side as the ptosis (my Rt) I think the pain does tend to occur later in the day, say midday onwards. I do not have it everyday, but notice it more when I have watched TV, which I generally tend to avoid doing as the lights and the frenetic camera work that seems trendy nowadays plays havoc with my vision. I end up with a right sided headache.
The other thing is I have right shoulder & arm weakness & the Rheumatologist reckons I have a trapped nerve (rotator cuff)
If I lay for too long on my ptosis side I can end up with swollen inflamed eye, face & shoulder.
According to the Neurologist, (he is one specialising in neuro-opthalmology) this is caused by the strain put on the brain trying to make sense of all the mixed signals it is receiving, hence the inflammation which results in headaches & strain. I find the most effective remedy is an ice pack on my head which relieves the symptoms faster than any pill.
The tip for the amber coloured glasses is useful thanks. I have some amber ones to reduce blue light but if they are taken off before you have worn them for about 6 hours they can cause a further breakdown in melatonin resulting in more insomnia.
I see the second orthoptist on 13th & will certainly let you know what she says. I don't blame you not wanting to take steroids.
All the best Gill
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AnnK
197 posts
Jul 07, 2010
1:05 PM
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Hi Gill
I find watching tv a strain too - as you say, all that frenetic camera work plays havoc. I've resorted to just listening to a lot of tv and having the setting on Sky tv for the blind, so that I can close my eyes and listen to quite a lot of programmes - it's where there's a kind of narration to explain what's going on. I also close my eyes and just listen to programmes where it's not essential to watch, e.g. the news, quiz programmes etc.
I too have shoulder and arm problems - pain and restricted mobility. It was hell (with the pain particularly) before my GP ran some blood tests and found that I was hypothyroid and vitamin D deficient and low in calcium. Gradually the pain improved and the mobility too - although not fully- with me taking levothyroxine and vit D and calcium supplements. I've noticed that I'm worsening again though - Got my thyroid hormones and calcium levels checked out which were okay, so I think that I need to get back to higher supplements of vit D - I lowered them during last summer a bit and probably didn't take enough during last winter. If, in a few weeks, I don't improve I'll go back and ask for another vit D blood test to see what's going on. Perhaps it's down to something else - I hope not! Anyway, I tell you this because my shoulder and arm pain was similar in nature to that of rotator cuff problems. One thing I've also noticed is that my lips and area surrounding them are always swollen in the mornings since I've had OMG.
I also agree - ice is often much better than taking pain killers for the headaches and strain. My freezer is full of ice packs!
Do tell me more about the amber coloured glasses that you use - Why do you reduce blue light? And it's very interesting about the melatonin aspect. I shall have to make a mental note to remember how I sleep the night of the days I wear my amber wrap-arounds. I sleep badly anyway, so it's difficult to tell, but I'll be more aware.
Look forward to hearing from you again when you feel up to it and to hearing how you got on with the orthoptist.
Best;
Ann
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Gill87440
8 posts
Jul 16, 2010
12:39 PM
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Hi Ann,
The visit to the orthoptist here was a waste of time.
My condition seemed to be way beyond her expertise.
The information on the coloured glasses can be found on www.LowBlueLights.com
For your information I am arranging to make a repeat visit to an orthoptist in London in September,I will delve further into 3rd cranial nerve then.
All the best,
Gill
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AnnK
202 posts
Jul 17, 2010
8:55 AM
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Hi Gill
Sorry to hear that the orthoptist wasn't able to help. I hope you are able to get some answers from the one in London.
The LowBlueLights website looks very interesting. The amber wrap-around over-glasses ones look very similar to the ones I got from the RNIB and might explain why I find them restful for my eyes. I shall take my time having a look around the site as, although I don't usually have difficulties getting off to sleep, I do have problems staying asleep, waking up many times a night and often feeling almost as tired in the mornings as I did when I went to bed.
Look forward to hearing how you get on in London.
Best wishes
Ann
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