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Title

Globe subluxation following steroid treatment for Myasthenia Gravis (MG)

Purpose	To describe a case of globe subluxation secondary to steroid treatment for MG.
Methods	A 57 year old male presented with vertical diplopia to our department. Ocular motility exam showed slight underaction of the left inferior rectus muscle. Exam was otherwise normal. Abs AchR were weakly positive, sfEMG was normal. The diagnosis of MG was made and treatment with pyridostigmine initiated. Because of progressive worsening of clinical symptoms (complete ptosis and diplopia) the neurologist increased the dose of pyridostigmine progressively and started plasmapheresis. However the restriction in eye motility and ptosis worsened. Oral methylprednisolone at increasing dose (up to 56 mg/day) was added to the treatment. Clinical exam at 8 months showed bilateral exophthalmos, restriction of abduction of the right eye, a significant cushoid facies weight gain. 5 months later he experienced a spontaneous globe subluxation on the left. He immediately repositioned the globe, resulting in a big corneal abrasion. He suffered from severe muscle weakness in his arms and legs secondary to steroid myopathy. He was referred to a neurologist, specialized in MG, who immediately tapered steroids and pyridostigmine and started tacrolimus.
Results	After the treatment adaptation the myopathy slowly diminished, together with a loss of weight. However he did experience another globe subluxation. We believe the spontaneous globe luxations were caused by weakness of the extra ocular muscles together with a gain of intraorbital fat both induced by excessive steroid dose. Tarsoraphy is considered to prevent recurrence.
Conclusion	Steroids are indicated for treatment of MG, however careful follow up is necessary to check for side effects. Treatment should be altered in case of serious side effects.
Conflict of interest	No

Authors 1

Last name	DAM
Initials	JF
Department	KULeuven
City	Leuven

Authors 2

Last name	CASSIMAN
Initials	C