Double trouble

A 78-year-old woman presented with vertical double vision. The Bielschowsky-Parks' three-step test suggested a left inferior rectus muscle paresis. Diagnostic testing confirmed the diagnosis of myasthenia gravis. Despite treatment with pyridostigmine bromide (mestinon) the diplopia persisted. She refused corticosteroid treatment and sought a second opinion, resulting in three unsuccessful strabismus surgeries to correct her ocular misalignment. The evaluation and management of ocular myasthenia gravis is reviewed and the appropriate timing of strabismus surgery is discussed.