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Ice Pack Test for Myasthenia Gravis LETTER to the EDITORS View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by RERO DOC Digital Library J Neurol (2003) 250:883–884 DOI 10.1007/s00415-003-1121-1 LETTER TO THE EDITORS Adam Czaplinski countries. According to previous we cooled the more affected eye. Andreas J. Steck publications local cooling improves The ice pack was then removed af- Peter Fuhr neuromuscular transmission, ter 2 minutes. After 10 minutes, whereas warming has the opposite three i. v. injections, one containing effect [1]. However, the precise 10 mg edrophonium and two Ice pack test for mechanism of this effect is unclear. placebo, were administered in a myasthenia gravis Reduction or inhibition of the ac- double blinded fashion by a nurse. tivity of acetylcholinesterase by Photographs were taken immedi- A simple, noninvasive and safe lowering temperature is a possible ately after cooling or 1 minute after diagnostic method mechanism [8]. The purpose of the injection. All pictures were re- present article is to be a reminder viewed by a blinded observer. Out- Received: 24 January 2003 of an alternate method to tensilon come measure was the effect of ice Accepted: 27 February 2003 testing that is simple and safe but or edrophonium on ptosis. seems to have fallen into oblivion Results: Five subjects improved in the neurological literature. with the ice test; however, in one of Sirs: Intravenous injection of the Design/Methods: Five patients them the edrophonium test was acetylcholinesterase inhibitor edro- with ptosis from previously undi- negative. All subjects with positive phonium (tensilon) is commonly agnosed myasthenia gravis and five response to orbital cooling were used in the diagnosis of myasthe- with non-myasthenic ptosis were subsequently shown to have myas- nia gravis (MG), because of rapid studied with the use of tensilon thenia gravis by other tests (ele- onset and short duration of its ef- testing, orbital cooling, and other vated titers of anti-acetylcholine fects. The estimated sensitivity of tests for MG such as repetitive receptor antibody and compound tensilon testing in myasthenia nerve stimulation and determina- muscle action potential (CMAP) gravis is high; however, false-nega- tion of antiacetylcholine receptor amplitude decrement to repetitive tive responses have been reported. antibody (AchR-ab) levels. Each stimulation greater than 20%). Pa- Tensilon, however, may produce se- patient was photographed before tients with non-myasthenic ptosis rious side effects, including signifi- ice or tensilon testing. In the ice (negative anti-acetylcholine recep- cant bradycardia, loss of conscious- test, the patient was asked to hold tor antibody titer and no decre- ness and death [4]. Consequently an ice pack (ice cube wrapped in a mental response in repetitive nerve its use has been restricted in surgical glove) over the closed eye stimulation tests) did not improve Switzerland and in other European with ptosis. If ptosis was bilateral, in either ice or edrophonium test. Fig. 1 (A) before testing; (B) after ice-test (ice application to the right eyelid); (C) after edrophonium test a) b) JON 1121 c) 884 No patient had a false-positive or with negative edrophonium test References paradoxical response to the ice test. were found in our study and also in No side effects, except for moderate the studies of Sethi et al. and Gol- 1. Borenstein S, Desmedt JE (1975) Local local discomfort in the ice test, nik et al. However, both ice and cooling in myasthenia. Improvement of neuromuscular failure. Arch Neurol 32: were observed. edrophonium tests yield also false 152–157 Discussion: According to our negative responses. According to 2. Ellis FD, Hoyt CS, Ellis FJ, Jeffery AR, limited data, the ice test seems to previous studies improvement in Sondhi N (2000) Extraocular muscle re- be relatively sensitive for the diag- eyelid elevation after the ice test is sponses to orbital cooling (ice test) for ocular myasthenia gravis diagnosis. J nosis of myasthenia gravis in pa- in part caused by rest [7]. A com- AAPOS 4:271–281 tients with ocular symptoms: in parison of both ice and sleep test in 3. Golnik KC, Pena R, Lee AG, Eggenberger our group all patients subsequently a group of 10 subjects with myas- ER (1999) An ice test for the diagnosis shown to have myasthenia gravis thenic ptosis and 15 with non- of myasthenia gravis. Ophthalmology 106:1282–1286 by other tests improved in ice test. myasthenic ptosis in a randomised 4. Ing EB, Ing SY,Ramocki JA (2000) The These results are in agreement with trial was performed by Kubis et al. complication rate of edrophonium test- the previously published studies. [5]. Whereas there was no improve- ing for suspected myasthenia gravis. Golnik et al. observed improvement ment in ptosis in non-myasthenic Can J Ophthalmol 35:141–144 in myasthenic ptosis after the ice subjects, in myasthenic patients the 5. Kubis KC, Danesh-Meyer HV,Savino PJ, Sergott RC (2000) The ice test versus test in 16 of 20 patients with myas- median improvement of ptosis rest test in myasthenia gravis. Ophthal- thenia gravis [3], Sethi et al. in 8 of with the rest test was 2 mm and mology 107:1195–1198 10 patients [8] and Lertchavanakul with the ice test was 4,5 mm. This 6. Lerchavanakul A, Gamnerdsiri P,Hirun- in 19 of 20 patients [6]. Although difference between the rest (sleep) wiwatkul P (2001) Ice test for ocular myasthenia gravis. J Med Assoc Thai 84 the sensitivity of the ice test was test and ice tests was significant (Suppl 1):S31–S36 not 100%, as has been also re- (p < 0.001). Both our results and re- 7. Movaghar M, Slavin ML (2000) Effect of ported [2, 5] these results support view of the literature confirm that local heat versus ice on blepharoptosis the validity of the ice test in the di- the ice test seems to be a reliable, resulting from ocular myasthenia. Ophthalmology 107:2209–2214 agnosis of MG. Moreover, the safe, simple, sensitive and specific 8. Sethi KD, Rivner MH, Swift TR (1987) specificity of the ice test appears to diagnostic method for the diagno- Ice pack test for myasthenia gravis. be very high. Patients with non- sis of myasthenia gravis in patients Neurology 37:1383–1385 myasthenic ptosis do not improve with ocular ptosis. However, the in the ice test [2, 3, 5, 6, 8]. The ice most important disadvantage of A. Czaplinski, MD (౧) · A. J. Steck · P.Fuhr test may also be useful in the diag- this method in comparison with Dept. of Neurology nosis of myasthenia gravis, even in the tensilon test is the inability to University Hospital Basel patients in whom edrophonium conduct this test in a double-blind Petersgraben 4 testing is negative. Patients with a fashion. 4031 Basel, Switzerland Tel.: +41-61/265-2525 positive response in the ice test but Fax: +41-61/265-4100 E-Mail: [email protected].
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