Atlas of Ophthalmology

Myasthenic Diplopia (Effect of Cold Test, Colour Image)

Systemic Diseases -> Immunologic Diseases
Male subject, 85 years of age, intermittent diplopia, ophthalmoplegia, and blepharoptosis; BCVA RA 0.4, LA 0.4; IOP RA 15 mmHg, LA 18 mmHg. Acetylcholine receptor (AchR) antibodies and muscle-specific kinase (MuSK) antibodies were determined. To present the diagnostic effect of the cold pack test as an office preliminary test in the differential diagnosis of myasthenic diplopia. A male patient (85 years of age) with a recent onset of diplopia, blepharoptosis and ophthalmoplegia had the cold pack applied for 5 minutes on both eyelids. The "ice test", involving orbital cooling through the application of a cold pack over closed eyelids, is a reliable clinical test for the diagnosis of ocular myasthenia gravis. We found a positive response to the cold pack test proved to be a reduction in blepharoptosis. The differential diagnosis of acquired strabismus is broad, including paretic strabismus, myasthenia gravis, and other myopathic disorders such as restrictive strabismus and chronic progressive external ophthalmoplegia. Saavedra et al. (1) suggested a cold test that favorably influences neuromuscular transmission for the diagnosis of ocular myasthenia. It was found (2) that the sensitivity for the detection of myasthenic diplopia by a cold pack was about 80% for a 5-minute application with a high specificity (98%). The authors concluded that the cold pack test had a high specificity and an acceptable sensitivity in the differential diagnosis of myasthenic diplopia. Literature: (1) J. Saavedra, R. Femminini, S. Kochen, J.C. deZarate. A cold test for myasthenia gravis [letter]. Neurology, 29 (1979), p. 1075 (2) Chatzistefanou KI, Kouris T, Iliakis E, Piaditis G, Tagaris G, Katsikeris N, Kaltsas G, Apostolopoulos M. The ice pack test in the differential diagnosis of myasthenic diplopia. Ophthalmology. 2009 Nov;116(11):2236-43.

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