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A patient is described who presented with an abrupt onset of diplopia in association with a drooping lid. The motility pattern was consistent with a pupil sparing oculomotor nerve palsy. In addition, the behavior of the palpebral fissure was characteristic of aberrant regeneration. Intravenous Tensilon resulted in a prompt elevation of the lid and improvement in eye movements. The differential diagnosis of a pupil sparing third nerve palsy should include myasthenia gravis.

We reviewed the records of 23 patients with systemic myasthenia gravis and blepharoptosis. The overall prognosis for improvement of blepharoptosis in these patients was favorable when multiple modes of therapy, including anticholinesterase medication, were used. Four of five patients with disabling blepharoptosis were stable enough after three to four years of their disease to consider corrective lid surgery. Two patients underwent levator resection with good results. Patients with systemic and ocular myasthenia gravis who are refractory to systemic therapy should be considered candidates for ptosis surgery when their blepharoptosis has been stable over a three- to four-year period.