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Controversies in Neurology |

Immunosuppressive or Surgical Treatment for Ocular Myasthenia Gravis

Pamela S. Chavis, MD; David E. Stickler, MD; Aljoeson Walker, MD
Arch Neurol. 2007;64(12):1792-1794. doi:10.1001/archneur.64.12.1792.
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Is there any other autoimmune disease treated by surgical removal of a gland? Does the evidence of autoimmunity in myasthenia gravis (MG) support medical treatment of significant ocular involvement? The basis for answering these questions must rest on an understanding of disease progression, the success of treatment, and the risk-benefit ratio for the patient. Although there is a high frequency of autoimmune disease in MG, there are no studies of any other autoimmune disease being treated by surgical removal of a gland or thymectomy. The surgical treatment of MG by thymectomy dates to the series of 20 patients with and without thymoma reported by Blalock1 in 1944; this treatment was innovative and was effective then and still is now, even in the immunomodulatory era. There is little doubt that the thymus is responsible for T-cell development and maintains the autoimmune response, but thymectomy for nonthymomatous MG may not offer any benefit over medical treatment alone. Myasthenia gravis respects the criteria for autoimmunity, and the suspected autoimmune pathogenesis was confirmed by anti–acetylcholine receptor (AChR) antibody identification.2 However, the natural history and degree of disease disability vs the adverse effects of medical therapy must be considered. In generalized MG (GMG), there is no debate as to the efficacy and importance of treatment.

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