Off-center presentation of ocular myasthenia

Myasthenia gravis is an autoimmune condition with varied presentations. In this, we report a 70 years old diabetic male who came complaining of diplopia. On examination, he had ptosis and restriction of extraocular movements on the right side with bilateral normal pupillary reflexes. We diagnosed him to have diabetic neuropathy initially, however his ptosis worsened, leading us to revise the diagnosis. Ice pack test was positive, repetitive nerve stimulation showed a decremental response, and serum acetylcholine receptor antibodies were positive, confirming the diagnosis of ocular myasthenia. We started the patient on oral pyridostigmine and steroids and his symptoms improved. This report emphasizes the need for a high degree of suspicion for the timely diagnosis of ocular myasthenia gravis.