J Korean Ophthalmol Soc.  2015 Feb;56(2):309-315. 10.3341/jkos.2015.56.2.309.

Two Cases with Positive Ice Tests Mimicking Ocular Myasthenia Gravis

• Seo EJ
• Park A
• Chung SA

• KMID: 2216020
• DOI: http://doi.org/10.3341/jkos.2015.56.2.309

Abstract

PURPOSE
To report two patients with positive ice tests who had diplopia and blepharoptosis caused by something other than ocular myasthenia gravis.
CASE SUMMARY
A 35-year-old female presented with a one-week history of inability to adduct the left eye and left blepharoptosis. Although the ice test was positive, serum anti-acetylcholine receptor binding antibody and the repetitive nerve stimulation test were negative. Brain angiography showed an aneurysm of the left posterior communicating artery, leading to the diagnosis of left pupil-sparing oculomotor nerve palsy. A 25-year-old female presented with an 8-month history of intermittent horizontal diplopia and blepharoptosis in the right eye. The ice test was positive, however serum anti-acetylcholine receptor binding antibody and the repetitive nerve stimulation test were negative. Anti-nuclear antibody was positive (titer 1:160).
CONCLUSIONS
The ice test is a useful screening test for myasthenia gravis. However, a series of differential diagnoses including blepharoptosis and ocular motility disorder should be considered because these conditions also show a positive result in the ice test.

Keyword

Anti-nuclear antibody; Ice test; Myasthenia gravis; Oculomotor nerve palsy

MeSH Terms

Adult
Aneurysm
Angiography
Arteries
Blepharoptosis
Brain
Diagnosis
Diagnosis, Differential
Diplopia
Female
Humans
Ice*
Mass Screening
Myasthenia Gravis*
Ocular Motility Disorders
Oculomotor Nerve Diseases
Ice

Figure

• 

  Figure 1. (A) Nine-cardinal gaze photographs of case I showing left blepharoptosis and severe limitation on adduction, infraduction, and moderate limitation on supraduction of the left eye. (B) Photographs showing improvement of left blepharoptosis following application of the ice pack: before (left column) and after applying ice pack for 2 minutes (right column). (C) Hess screen chart revealing left oculomotor nerve palsy. (D) Repetitive nerve stimulation test showing normal response of the orbicularis oculi.

• 

  Figure 2. (A) Oblique anterior, (B) lateral (magnified), (C) oblique posterior three-dimension reconstructed digital subtraction an-giography showing a 5.7 × 3.0 × 3.4-cm-sized saccular aneurysm on the left posterior communicating artery (indicated by white arrows).

• 

  Figure 3. (A) Nine-cardinal gaze photographs of case II one week after the initial visit showing right blepharoptosis and slight limitation on supraduction of the right eye. (B) Photographs showing improvement of right blepharoptosis following application of the ice pack: before (left column) and after applying ice pack for 2 minutes (right column). (C) Hess screen chart revealing underaction of the right superior rectus. (D) Repetitive nerve stimulation test showing normal response of the orbicularis oculi.

Reference

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