{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T05:57:47Z","timestamp":1790229467236,"version":"4.1.0"},"reference-count":65,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,11,3]],"date-time":"2025-11-03T00:00:00Z","timestamp":1762128000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Neurol."],"abstract":"<jats:p>Ocular myasthenia gravis (OMG) has no agreed-upon diagnostic and management criteria, leading to misdiagnoses and often misguided treatments. The purpose of this minireview is to provide guidance to clinicians who encounter possible OMG patients. We cite relevant literature and the recommendations for diagnosis and therapy based on the authors\u2019 extensive experience in OMG. This report provides sound recommendations based on the authors\u2019 successes and failures, coupled with relevant literature in the myasthenia gravis field.<\/jats:p>","DOI":"10.3389\/fneur.2025.1678151","type":"journal-article","created":{"date-parts":[[2025,11,3]],"date-time":"2025-11-03T05:21:38Z","timestamp":1762147298000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":3,"title":["Ocular myasthenia gravis management"],"prefix":"10.3389","volume":"16","author":[{"given":"Mark J.","family":"Kupersmith","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gil I.","family":"Wolfe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Henry","family":"Kaminski","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2025,11,3]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"142","DOI":"10.1186\/1471-2377-14-142","article-title":"Quality of life in purely ocular myasthenia in Japan","volume":"14","author":"Suzuki","year":"2014","journal-title":"BMC Neurol"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"117274","DOI":"10.1016\/j.jns.2020.117274","article-title":"Ocular myasthenia gravis\u2013how effective is low dose prednisone long term?","volume":"420","author":"Verma","year":"2021","journal-title":"J Neurol Sci"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"156","DOI":"10.1136\/jnnp.62.2.156","article-title":"Ocular myasthenia gravis: response to long-term immunosuppressive treatment","volume":"62","author":"Sommer","year":"1997","journal-title":"J Neurol Neurosurg Psychiatry"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"170","DOI":"10.1212\/wnl.34.2.170","article-title":"Myasthenia gravis: prolonged treatment with steroids","volume":"34","author":"Sghirlanzoni","year":"1984","journal-title":"Neurology"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"212","DOI":"10.1097\/WNO.0b013e3182536558","article-title":"Safety of prednisone for ocular myasthenia gravis","volume":"32","author":"Bruce","year":"2012","journal-title":"J Neuroophthalmol"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"291","DOI":"10.1002\/ana.410150316","article-title":"Long-term corticosteriod treatment of myasthenia gravis: report of 116 patients","volume":"15","author":"Pascuzzi","year":"1984","journal-title":"Ann Neurol"},{"key":"ref7","first-page":"S9","article-title":"Osteoporosis in steroid-treated patients with polymyalgia rheumatica and temporal arteritis: what is the magnitude and rate over 1 year","volume":"35","author":"Paget","year":"1992","journal-title":"Arthritis Rheum"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"382","DOI":"10.1007\/s002239900352","article-title":"Prevention of corticosteroid-induced osteoporosis with alendronate in sarcoid patients","volume":"61","author":"Gonnelli","year":"1997","journal-title":"Calcif Tissue Int"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"599","DOI":"10.1056\/NEJMoa2023386","article-title":"Avacopan for the treatment of ANCA-associated vasculitis","volume":"384","author":"Jayne","year":"2021","journal-title":"N Engl J Med"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"420","DOI":"10.1056\/NEJM199708073370609","article-title":"Preventing glucocorticoid-induced osteoporosis","volume":"337","author":"Reid","year":"1997","journal-title":"N Engl J Med"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"292","DOI":"10.1056\/NEJM199807303390502","article-title":"Alendronate for the prevention and treatment of glucocorticoid-induced osteoporosis","volume":"339","author":"Saag","year":"1998","journal-title":"NEJM"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"543","DOI":"10.1136\/annrheumdis-2016-210002","article-title":"Development of a glucocorticoid toxicity index (GTI) using multicriteria decision analysis","volume":"76","author":"Miloslavsky","year":"2017","journal-title":"Ann Rheum Dis"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"243","DOI":"10.1001\/archneur.60.2.243","article-title":"Development of generalized disease at 2 years in patients with ocular myasthenia gravis","volume":"60","author":"Kupersmith","year":"2003","journal-title":"Arch Neurol"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"472","DOI":"10.1111\/j.1749-6632.1987.tb51317.x","article-title":"The course of myasthenia gravis and therapies affecting outcome","volume":"505","author":"Grob","year":"1987","journal-title":"Ann N Y Acad Sci"},{"key":"ref15","doi-asserted-by":"crossref","first-page":"985","DOI":"10.1001\/archopht.1959.04220060057010","article-title":"Evaluation of ocular signs and symptoms in myasthenia gravis","volume":"62","author":"Schlezinger","year":"1959","journal-title":"AMA Arch Ophthalmol"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"516","DOI":"10.1002\/ana.410140504","article-title":"Prognosis of ocular myasthenia","volume":"14","author":"Bever","year":"1983","journal-title":"Ann Neurol"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"31","DOI":"10.1111\/j.1600-0404.1988.tb06970.x","article-title":"Ocular myasthenia: diagnostic and therapeutic problems","volume":"77","author":"Evoli","year":"1988","journal-title":"Acta Neurol Scand"},{"key":"ref18","doi-asserted-by":"crossref","first-page":"1121","DOI":"10.1136\/jnnp.52.10.1121","article-title":"The natural course of myasthenia gravis: a long term follow up study","volume":"52","author":"Oosterhuis","year":"1989","journal-title":"J Neurol Neurosurg Psychiatry"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"622","DOI":"10.1002\/mus.25971","article-title":"Ocular presentation of myasthenia gravis: a natural history cohort","volume":"57","author":"Kamarajah","year":"2018","journal-title":"Muscle Nerve"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"99","DOI":"10.1016\/j.ajo.2019.04.017","article-title":"Incidence, epidemiology, and transformation of ocular myasthenia gravis: a population-based study","volume":"205","author":"Hendricks","year":"2019","journal-title":"Am J Ophthalmol"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"1517","DOI":"10.1016\/j.ophtha.2015.03.010","article-title":"Prognosis of ocular myasthenia gravis: retrospective multicenter analysis","volume":"122","author":"Nagia","year":"2015","journal-title":"Ophthalmology"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"802","DOI":"10.1001\/archneur.1996.00550080128020","article-title":"Beneficial effects of corticosteroids on ocular myasthenia gravis","volume":"53","author":"Kupersmith","year":"1996","journal-title":"Arch Neurol"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"1330","DOI":"10.1136\/bjo.2004.063404","article-title":"Ocular motor dysfunction and ptosis in ocular myasthenia gravis: effects of treatment","volume":"89","author":"Kupersmith","year":"2005","journal-title":"BJO"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"795","DOI":"10.1212\/wnl.24.8.795","article-title":"Oral corticosteroids in the treatment of ocular myasthenia gravis","volume":"24","author":"Fischer","year":"1974","journal-title":"Neurology"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"131","DOI":"10.1016\/j.jns.2003.08.017","article-title":"The effect of prednisone on the progression from ocular to generalized myasthenia gravis","volume":"217","author":"Monsul","year":"2004","journal-title":"J Neurol Sci"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"e179742","DOI":"10.1172\/JCI179742","article-title":"Myasthenia gravis: the future is here","volume":"134","author":"Kaminski","year":"2024","journal-title":"J Clin Invest"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"220","DOI":"10.1196\/annals.1405.037","article-title":"Extraocular muscle susceptibility to myasthenia gravis: unique immunological environment?","volume":"1132","author":"Soltys","year":"2008","journal-title":"Ann N Y Acad Sci"},{"key":"ref28","doi-asserted-by":"crossref","first-page":"642","DOI":"10.1001\/jamaneurol.2015.0203","article-title":"Clinical features and diagnostic usefulness of antibodies to clustered acetylcholine receptors in the diagnosis of seronegative myasthenia gravis","volume":"72","author":"Cruz","year":"2015","journal-title":"JAMA Neurol"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"519","DOI":"10.1097\/01.wco.0000180660.57801.3f","article-title":"Neuromuscular junction autoimmune disease: muscle specific kinase antibodies and treatments for myasthenia gravis","volume":"18","author":"Vincent","year":"2005","journal-title":"Curr Opin Neurol"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"139","DOI":"10.1016\/j.jaut.2013.12.004","article-title":"A comprehensive analysis of the epidemiology and clinical characteristics of anti-LRP4 in myasthenia gravis","volume":"52","author":"Zisimopoulou","year":"2014","journal-title":"J Autoimmun"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"1099","DOI":"10.1001\/jamaneurol.2016.2032","article-title":"Clinical characteristics of patients with double-seronegative myasthenia gravis and antibodies to cortactin","volume":"73","author":"Cort\u00e9s-Vicente","year":"2016","journal-title":"JAMA Neurol"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"101","DOI":"10.1111\/j.1749-6632.2012.06787.x","article-title":"Biomarker development for myasthenia gravis","volume":"1275","author":"Kaminski","year":"2012","journal-title":"Ann N Y Acad Sci"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"e91927","DOI":"10.1371\/journal.pone.0091927","article-title":"Analysis of serum miRNA profiles of myasthenia gravis patients","volume":"9","author":"Nogales-Gadea","year":"2014","journal-title":"PLoS One"},{"key":"ref34","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s41232-017-0058-1","article-title":"Circulating plasma microRNA profiling in patients with polymyositis\/dermatomyositis before and after treatment: miRNA may be associated with polymyositis\/dermatomyositis","volume":"38","author":"Hirai","year":"2018","journal-title":"Inflammat Regeneration"},{"key":"ref35","doi-asserted-by":"publisher","first-page":"1882","DOI":"10.1002\/art.37966","article-title":"Glucocorticoids suppress T cell function by up-regulating microRNA-98","volume":"65","author":"Davis","year":"2013","journal-title":"Arthritis Rheum"},{"key":"ref36","doi-asserted-by":"publisher","first-page":"102438","DOI":"10.1016\/j.jaut.2020.102438","article-title":"Clinical significance of miRNAs in autoimmunity","volume":"109","author":"Zhang","year":"2020","journal-title":"J Autoimmun"},{"key":"ref37","doi-asserted-by":"publisher","first-page":"2041","DOI":"10.1007\/s00018-016-2167-4","article-title":"Contribution of MicroRNAs to autoimmune diseases","volume":"73","author":"Garo","year":"2016","journal-title":"Cell Mol Life Sci"},{"key":"ref38","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s13075-016-1023-0","article-title":"MicroRNA-125b: association with disease activity and the treatment response of patients with early rheumatoid arthritis","volume":"18","author":"Hruskova","year":"2016","journal-title":"Arthritis Res Ther"},{"key":"ref39","doi-asserted-by":"publisher","first-page":"104388","DOI":"10.1016\/j.phrs.2019.104388","article-title":"MicroRNA signature associated with treatment response in myasthenia gravis: A further step towards precision medicine","volume":"148","author":"Cavalcante","year":"2019","journal-title":"Pharmacol Res"},{"key":"ref40","doi-asserted-by":"publisher","first-page":"1074","DOI":"10.3389\/fimmu.2020.01074","article-title":"Role of miRNAs in normal and myasthenia gravis thymus","volume":"11","author":"Cron","year":"2020","journal-title":"Front Immunol"},{"key":"ref41","doi-asserted-by":"publisher","first-page":"164","DOI":"10.1016\/j.jneuroim.2018.05.003","article-title":"Circulating microrna miR-21-5p, miR-150-5p and miR-30e-5p correlate with clinical status in late onset myasthenia gravis","volume":"321","author":"Sabre","year":"2018","journal-title":"J Neuroimmunol"},{"key":"ref42","doi-asserted-by":"publisher","first-page":"213","DOI":"10.3389\/fimmu.2020.00213","article-title":"Circulating miRNAs as potential biomarkers in myasthenia gravis: tools for personalized medicine","volume":"11","author":"Sabre","year":"2020","journal-title":"Front Immunol"},{"key":"ref43","doi-asserted-by":"publisher","first-page":"90","DOI":"10.1016\/j.jns.2015.06.019","article-title":"Disease specific signature of circulating miR-150-5p and miR-21-5p in myasthenia gravis patients","volume":"356","author":"Punga","year":"2015","journal-title":"J Neurol Sci"},{"key":"ref44","doi-asserted-by":"publisher","first-page":"740","DOI":"10.3390\/cells11040740","article-title":"Towards personalized medicine in myasthenia gravis: role of circulating microRNAs miR-30e-5p, miR-150-5p and miR-21-5p","volume":"11","author":"Beretta","year":"2022","journal-title":"Cells"},{"key":"ref45","doi-asserted-by":"publisher","first-page":"605902","DOI":"10.3389\/fneur.2020.605902","article-title":"Controversies in ocular myasthenia gravis","volume":"11","author":"Evoli","year":"2020","journal-title":"Front Neurol"},{"key":"ref46","volume-title":"Binocular vision and ocular motility","author":"Von Noorden","year":"2002"},{"key":"ref47","doi-asserted-by":"publisher","first-page":"e1800","DOI":"10.1212\/WNL.0000000000010619","article-title":"Comparison of ice pack test and single-fiber EMG diagnostic accuracy in patients referred for myasthenic ptosis","volume":"95","author":"Giannoccaro","year":"2020","journal-title":"Neurology"},{"key":"ref48","first-page":"178","volume-title":"Ocular myasthenia: diagnosis and treatment neuro-ophthalmology enters the nineties","author":"Kupersmith","year":"1988"},{"key":"ref49","doi-asserted-by":"publisher","first-page":"459","DOI":"10.1016\/j.nmd.2006.05.006","article-title":"A systematic review of diagnostic studies in myasthenia gravis","volume":"16","author":"Benatar","year":"2006","journal-title":"Neuromuscul Disord"},{"key":"ref50","doi-asserted-by":"publisher","first-page":"e213498","DOI":"10.1212\/WNL.0000000000213498","article-title":"Risk of false acetylcholine receptor autoantibody positivity by radioimmunoprecipitation assay in clinical practice","volume":"104","author":"Zara","year":"2025","journal-title":"Neurology"},{"key":"ref51","doi-asserted-by":"publisher","first-page":"251","DOI":"10.1097\/00041327-200312000-00002","article-title":"Immunotherapy of ocular myasthenia gravis reduces conversion to generalized myasthenia gravis","volume":"23","author":"Mee","year":"2003","journal-title":"J Neuroophthalmol"},{"key":"ref52","doi-asserted-by":"publisher","first-page":"e80172","DOI":"10.7759\/cureus.80172","article-title":"Effectiveness of immunosuppressive therapy in preventing the progression of ocular myasthenia gravis to generalized myasthenia gravis: a systematic review and meta-analysis","volume":"17","author":"Nall","year":"2025","journal-title":"Cureus"},{"key":"ref53","doi-asserted-by":"publisher","first-page":"432","DOI":"10.1016\/j.clineuro.2012.06.013","article-title":"The predictive value of the presence of different antibodies and thymus pathology to the clinical outcome in patients with generalized myasthenia gravis","volume":"115","author":"Nikolic","year":"2013","journal-title":"Clin Neurol Neurosurg"},{"key":"ref54","doi-asserted-by":"publisher","first-page":"416","DOI":"10.1002\/jca.21694","article-title":"Excellent response to therapeutic plasma exchange in myasthenia gravis patients irrespective of antibody status","volume":"34","author":"Usmani","year":"2019","journal-title":"J Clin Apher"},{"key":"ref55","doi-asserted-by":"publisher","first-page":"1296","DOI":"10.1093\/aje\/kws375","article-title":"Use of azathioprine and the risk of cancer in inflammatory bowel disease","volume":"177","author":"Pasternak","year":"2013","journal-title":"Am J Epidemiol"},{"key":"ref56","doi-asserted-by":"publisher","first-page":"1604","DOI":"10.1038\/ajg.2009.745","article-title":"Risk of cancer in inflammatory bowel disease treated with azathioprine: a UK population-based case\u2013control study","volume":"105","author":"Armstrong","year":"2010","journal-title":"Am J Gastroenterol"},{"key":"ref57","doi-asserted-by":"publisher","first-page":"249","DOI":"10.1196\/annals.1405.031","article-title":"Lessons from two trials of mycophenolate mofetil in myasthenia gravis","volume":"1132","author":"Sanders","year":"2008","journal-title":"Ann N Y Acad Sci"},{"key":"ref58","doi-asserted-by":"publisher","first-page":"344","DOI":"10.1159\/000347068","article-title":"Tacrolimus monotherapy: a promising option for ocular myasthenia gravis","volume":"69","author":"Yagi","year":"2013","journal-title":"Eur Neurol"},{"key":"ref59","doi-asserted-by":"publisher","first-page":"30","DOI":"10.1016\/j.jns.2018.10.027","article-title":"Ocular myasthenia gravis patients following the administration of tacrolimus and steroids","volume":"396","author":"Omata","year":"2019","journal-title":"J Neurol Sci"},{"key":"ref60","doi-asserted-by":"publisher","first-page":"511","DOI":"10.1056\/NEJMoa1602489","article-title":"Randomized trial of thymectomy in myasthenia gravis","volume":"375","author":"Wolfe","year":"2016","journal-title":"NEJM"},{"key":"ref61","doi-asserted-by":"crossref","first-page":"259","DOI":"10.1016\/S1474-4422(18)30392-2","article-title":"Long-term effect of thymectomy in patients with non-thymomatous myasthenia gravis treated with prednisone: 2-year extension of the MGTX randomized trial","volume":"18","author":"Wolfe","year":"2019","journal-title":"Lancet Neurol"},{"key":"ref62","doi-asserted-by":"publisher","first-page":"2449","DOI":"10.1007\/s13311-021-01129-z","article-title":"Thymectomy and risk of generalization in patients with ocular myasthenia gravis: a multicenter retrospective cohort study","volume":"18","author":"Li","year":"2021","journal-title":"Neurotherapeutics"},{"key":"ref63","doi-asserted-by":"publisher","first-page":"100541","DOI":"10.1016\/j.ensci.2024.100541","article-title":"Myasthenia gravis: the evolving therapeutic landscape","volume":"37","author":"Wolfe","year":"2024","journal-title":"eNeurologicalSci"},{"key":"ref64","doi-asserted-by":"publisher","first-page":"842","DOI":"10.1001\/archneur.1986.00520080080028","article-title":"The office Tensilon test for ocular myasthenia gravis","volume":"43","author":"Seybold","year":"1986","journal-title":"Arch Neurol"},{"key":"ref65","doi-asserted-by":"publisher","first-page":"761","DOI":"10.1001\/archopht.1982.01030030765008","article-title":"Combined use of neostigmine and ocular motility measurements in the diagnosis of myasthenia gravis","volume":"100","author":"Miller","year":"1982","journal-title":"Arch Ophthalmol"}],"container-title":["Frontiers in Neurology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2025.1678151\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,11,3]],"date-time":"2025-11-03T05:21:39Z","timestamp":1762147299000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2025.1678151\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,3]]},"references-count":65,"alternative-id":["10.3389\/fneur.2025.1678151"],"URL":"https:\/\/doi.org\/10.3389\/fneur.2025.1678151","relation":{},"ISSN":["1664-2295"],"issn-type":[{"value":"1664-2295","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,11,3]]},"article-number":"1678151"}}