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Paper text:
myasthenia gravis ( mg ) , an autoimmune disease , impedes the postsynaptic acetylcholine receptors at the neuromuscular junction.1 ocular mg is a representative manifestation of this entity in which blepharoptosis and/or eye movement disturbances are often encountered.2 in general , up to 85% of all myasthenic patients show the anticholinesterase receptor antibody in serum , but only about 50% of patients demonstrate ocular muscle weakness.3 although cholinesterase inhibitors with or without steroids are commonly used as a treatment modality , they are , occasionally , less effective for ocular symptoms.4 in such a case , especially for ptosis without any eye movement disorders , ptosis surgery is often performed .
this paper presents an ocular mg case with eyelid dysfunction , in which cholinesterase inhibitors and steroids did not work sufficiently , but surgical treatment successfully improved the symptom .
a 39-year - old woman was diagnosed with mg when she was 8 years old . with a positive edrophonium test and detectable serum acetylcholine receptor antibody ,
the diagnosis of ocular mg was confirmed in addition to the unresponsiveness to treatment with pyridostigmine and steroids at 31 years of age . despite long - term treatment with steroids , she had difficulty opening both eyes , which caused stiff shoulders and headaches .
as she showed bilateral 3 mm levator function ( figure 1a ) without any eye movement disturbances , bilateral frontalis sling procedures were performed with an autologous fascia lata .
the skin incision was made 6 mm from the eyelid margin , and the central area of the upper brow margin was also incised ( figure 2a ) .
a tunnel was made from the brow incision through the suborbicularis oculi layer , and reached the pretarsal area .
the branched fascia lata was sutured with 60 nylon ( sigma , tokyo , japan ) on the tarsal plate and then the upper eyelid curvature was confirmed by pulling the fascia through the suborbicularis tunnel ( figure 2b ) . after the upper eyelid height was adjusted appropriately with a trial suture at the brow incision , the fascia was fixed at the subcutaneous tissue of the brow .
one year after the operation , the upper eyelids showed symmetrically appropriate heights ( figure 1b ) .
the patient did not demonstrate exposure keratitis , wound infection , lagophthalmos , or ptosis in the 6 months following the operation .
the frontalis sling surgery for ptosis by ocular mg accomplished functionally and cosmetically good outcomes . as the levator function of the patient was bilaterally 3 mm ,
in general , ptosis with less than 4 mm levator function needs a sling procedure,5 but with more levator function , levator advancement surgery is applied.6 as an excessive advancement of levator often leads to an eyelid - eyeball dissociation , causing dry eyes , a sling procedure should be used in such a case . in the past , numerous materials have been used for slings like silicone rods , gore - tex , and autologous tissue graft.5,79 the autologous graft from fascia lata was chosen rather than the artificial material in terms of its histocompatibility . although the patient did not show any eye movement disturbances , mg patients often show eye movement disturbances simultaneously with ptosis.10 bilateral ptosis surgery should be avoided in such a case to prevent postoperative diplopia . in this situation ,
many treatment modalities had been given to the patient , but her condition did not show definite improvement . generally in mg , anticholinesterases ( cholinesterase inhibitors )
although steroids are of great short - term benefit in most patients with ocular mg , the side effects associated with steroids may prevent long - term use.10 therapeutic effect of thymectomy is controversial for ocular mg .
therefore , a patient refractory to any medical treatments is a good candidate for ptosis surgery . in conclusion
, this paper reports an ocular mg case with eyelid dysfunction , in which cholinesterase inhibitors and steroids did not work sufficiently , but surgical treatment successfully improved the symptom .
a sling procedure with an autologous fascia was suitable for correcting poor levator function of an ocular mg case .
a 39-year - old woman was diagnosed with myasthenia gravis when she was 8 years old . 
 although many treatments  such as cholinesterase inhibitors and steroids  had been given to the patient , her condition did not improve sufficiently . 
 as she demonstrated bilateral 3 mm levator function without any eye movement disturbances , bilateral frontalis sling procedures were performed with an autologous fascia lata . 
 one year after the operation , the operated upper eyelids showed symmetrically appropriate heights with good functional outcome . a sling procedure with an autologous fascia lata was suitable for correcting poor levator function of an ocular myasthenia gravis case .