Acquired diplopia or ptosis: laboratory tests (myasthenia gravis, microvascular cause, giant cell arteritis, orbitopathy)
BioMG follows French guidelines. Adapt it to the guidelines and the tests available where you practise.
Isolated ocular motor palsy after age 50
Laboratory tests (the same day)
- CRP (urgently: giant cell arteritis)
- FBC
- Fasting plasma glucose
Also consider
Fluctuating diplopia or ptosis: suspected myasthenia gravis
Laboratory tests
- Acetylcholine receptor antibodies (anti-AChR)
- Anti-MuSK antibodies (if anti-AChR negative; usually requested by the neurologist)if neededThe PNDS recommends testing for anti-MuSK only if anti-AChR are negative; they are present in 40% of generalised myasthenia without anti-AChR [2].
- TSH
- Anti-TPO antibodies (looking for associated thyroiditis)if neededThe PNDS asks to look systematically for an associated thyroid dysfunction (5 to 10% of patients) by T4, TSH and anti-thyroid antibodies [2].
Diplopia with exophthalmos or eyelid retraction: thyroid eye disease
Laboratory tests
- TSH
- Free T4if needednon-French guidelineGraves' disease is confirmed by biochemical thyrotoxicosis with positive TSH receptor antibodies [5]; see the “Hyperthyroidism” page.
- Free T3if needednon-French guidelineGraves' disease is confirmed by biochemical thyrotoxicosis with positive TSH receptor antibodies [5]; see the “Hyperthyroidism” page.
- TSH receptor antibodies (TRAb)if needednon-French guidelineThe European recommendation recommends TRAb measurement for the diagnosis of Graves' disease [5]; a high level is also a risk factor for orbitopathy [6].
Sources (7)
- Tamhankar MA, Biousse V, Ying GS, Prasad S, Subramanian PS, Lee MS, et al. Isolated third, fourth, and sixth cranial nerve palsies from presumed microvascular versus other causes: a prospective study. Ophthalmology. 2013;120(11):2264-9.
- Centre de référence de pathologie neuromusculaire Paris-Est. Protocole national de diagnostic et de soins (PNDS) : Myasthénie autoimmune. Juillet 2015 (publié sur le site de la HAS).
- Assurance maladie. Nomenclature des actes de biologie médicale (NABM), version 105 : actes 1492 (autoanticorps antirécepteur de l'acétylcholine) et 1488 (autoanticorps antirécepteurs de TSH).
- Wiendl H, Abicht A, Chan A, Della Marina A, et al. Guideline for the management of myasthenic syndromes. Ther Adv Neurol Disord. 2023;16:17562864231213240 (version anglaise de la recommandation de la Deutsche Gesellschaft für Neurologie, DGN).
- Kahaly GJ, Bartalena L, Hegedüs L, Leenhardt L, Poppe K, Pearce SH. 2018 European Thyroid Association Guideline for the Management of Graves' Hyperthyroidism. Eur Thyroid J. 2018;7(4):167-86.
- Bartalena L, Kahaly GJ, Baldeschi L, Dayan CM, Eckstein A, Marcocci C, et al. The 2021 European Group on Graves' orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves' orbitopathy. Eur J Endocrinol. 2021;185(4):G43-G67.
- Burch HB, Perros P, Bednarczuk T, et al. Management of thyroid eye disease: a Consensus Statement by the American Thyroid Association and the European Thyroid Association. Eur Thyroid J. 2022;11(6):e220189.