Neurology Ophthalmology - Dr. McCauley


12.15.2008 - Neurology Ophthalmology - Dr. McCauley

On Friday, December 15th, 2008, I have a meeting with a doctor at the Vision Clinic for the problems with my double vision on the right side.  Note: For a full explanation of the Pathophysiology and Treatment & Diagnosis, see the end of this web page!

First I met with a specialist who checked out my vision and determined my left eye was about 20/20 and the right was slightly less.

Second, I met a doctor who did more testing and tried to correct my vision with lenses and so on.  He dilated my eyes and viewed the insides and took notes. He had a book on vision problems and of course, was looking at the rare types of diseases.  He finally called Dr. McCauley, a top neurology ophthalmologist from the University of California  Medical Center.  I started to explain the problems and he told me to be quiet!  Yes sir!  Then said he wanted me to answer his questions in one or two words only!  Excuse me!

After about three minutes and five questions or so, he said I probably have Ocular Myasthenia Gravis.  He said there is no cure.... and it is a rare disease.  The synapses in the brain do not send messages correctly to the muscles and he said there is a drug that causes the chemical substance in the synapses to increase in volume causing the messages to be stronger and hopefully will correct the problem, at least for the time being.

Dr. McCauley said sometimes the medication causes some patients to have an upset stomach, shortness of breath, weak legs, sweats and heart palpitations.  If I have any symptoms I should stop the medication and call the Vision Clinic. 

I went to the pharmacy and they said the medication, Pyridostigmine Bromide at 60 MG a tab, was the weakest dosage to be administrated and to take one pill three times a day.  The doctor said hopefully in a few days I should see an improvement.  I have another appointment on January 13th 2009 as a follow up.  They also gave me medicine for to take every morning just to ensure my stomach doesn't get upset.  It is Omeprazole - 20 MG a capsule and it is take once a day in the morning!

The doctor also had me go for a blood draw for a thyroid test and this Friday I will see Dr. Maas to see if the previous blood draw had signs of any type of infection that could cause this.  Plus the doctor upgraded the MRI on Friday afternoon to include not only the contrast but a special scan of my eye balls!   Plus I will go on January 15th 2009 to see Dr. Rutar, Professor of Ophthalmology at the University of California Medical Center.

So we shall see after a month if the diagnosis is correct and if the medication is helping!


This is the branch of medicine which deals with the diseases and surgery of the visual pathways, including the eye, brain, and areas surrounding the eye, such as the larimal system and eyelids.   By convention the term ophthalmologist is more restricted and implies a medically trained surgical specialist. Since ophthalmologists perform operations on eyes, they are generally categorized as surgeons.

The word ophthalmology comes from the Greel roots ophthalmos meaning eye and logos meaning word, thought or discourse; ophthalmology literally means "The science of eyes." As a discipline it applies to animal eyes also, since the differences from human practice are surprisingly minor and are related mainly to differences in anatomy or prevalence, not differences in disease processes.



In the normal condition, muscle contraction is a result of electrical signals sent from the central nervous system to muscle fibers via nerve impulses. At the neuromuscular junction, this electrical message is converted into a chemical message, as a chemical, acetyl choline (ACh), is released from nerve fibers and attaches to corresponding ACh receptors on the muscle fiber.

In MG, antibodies are produced that block ACh receptors, preventing ACh molecule binding to the receptor and leading to a breakdown in communication between the nervous system and the muscle, resulting in muscle fatigue, and sometimes paralysis. Autoantibodies against ACh receptors are detectable in 70-90% of patients with generalized MG, but only 50% in ocular myasthenia.

Treatment and Prognosis:

The prognosis tends to be good for patients with MG. It is often best not to treat mild cases of MG. Management of MG necessitates avoidance of medications that can worsen neuromuscular transmission, such as aminoglycoside antibiotics, beta-blockers and chloroquine. Additionally, anti-arrhythmics, calcium channel blockers, some anticonvulsants and intravenous iodinated contrast should be avoided.

If symptoms are moderate, oral anticholinesterase agents (ie. Mestinon) can relieve a large majority of the ocular symptoms, with proper adjustments of dose and dosing intervals. Steroid therapy is controversial, in that some data suggests early immunosuppression may reduce progression to generalized MG, but this choice must be made carefully, in light of the commonly associated steroid side effects and the difficulty in weaning patients from steroids without exacerbation of symptoms.

Additionally, MG patients should be examined for thymomas, and if found, should undergo surgery to address this condition. A prophylactic thymectomy is controversial, but has been shown to be helpful in young MG patients with acute disease within 3 years of disease onset, in patients with enlarged thymus glands and for whom surgery is low-risk, and patients with generalized MG who are unresponsive to medical treatment.

Patients with ocular myasthenia are usually treated initially with anticholinesterase medication. If ineffective, patients are then started on steroid therapy. Because ocular MG is a less severe disease than the generalized form, and it may not progress, thymectomy is usually delayed for several years to allow for spontaneous remission or generalization of the disease.

The symptoms of ocular MG can also be addressed by non-medicinal means. Ptosis can be corrected with placement of crutches on eyeglasses and with ptosis tape to elevate eyelid droop. Diplopia can be addressed by occlusion with eye patching, frosted lens, occluding contact lens or by simply placing opaque tape over a portion of eyeglasses. Also, plastic prisms (Fresnel prisms) can be attached to eyeglasses of a diplopic patient, allowing for alignment of vision from both eyes in the affected direction, but are often problematic if the degree of muscle weakness, and therefore ocular misalignment, fluctuates frequently.

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  Charles Walter Buntjer

San Francisco California
Created on: 2008.12.15  

Updated on: 2008.12.15