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Various toxicities and first report of globe subluxation: case report A 57-year-old man developed abdominal cramps and unspecified gastrointestinal side effects duing treatment with pyridostigmine for myasthenia gravis. He also developed globe subluxation, weight gain, cushingoid facies, bilateral exophthalmos and steroid myopathy during treatment with methylprednisolone for myasthenia gravis [not all outcomes stated]. The man presented with fluctuating vertical diplopia. Based on investigations, a diagnosis of myasthenia gravis was made. He started receiving pyridostigmine at increasing dosage reaching 720mg and showed a good clinical response initially. However, over the following 2 months, his ocular symptoms worsened, and he started to experience abdominal cramps secondary to pyridostigmine. The man’s dose of pyridostigmine was reduced and plasmapheresis was initiated. Three months later, he developed ptosis of his left eye and developed generalised myasthenia gravis. Subsequently, he started receiving oral methylprednisolone 64mg and the dose of pyridostigmine was increased to 720mg resulting in rapid clinical improvement. One year following the initial diagnosis, he presented again with sudden protrusion of the left eye with inability to close the eyelids upon awakening, which suggested globe subluxation. He pushed the globe back himself; however, he developed a big corneal abrasion. At that time, he had been receiving methylprednisolone 58mg for the past 6 months and pyridostigmine had been tapered to 360mg due to unspecified gastrointestinal side effects. Further investigations showed improvement of ductions. Hence, he was treated with prostaglandin. He also developed steroid myopathy, cushingoid facies, bilateral exophthalmos and gained 30kg of weight secondary to methylprednisolone. He could not climb stairs or carry a bucket of water due to myopathy. He was then referred to a different neurologist, who tapered the dose of methylprednisolone and pyridostigmine. Over the following 10 weeks, the dose of methylprednisolone was tapered to 4mg resulting in quick remission, and subsequently, it was withdrawn. Over the following 10 weeks, a new subluxation occurred. To avoid further subluxation, tarsorrhaphy was performed. Dam J, et al. Globe subluxation following long-term high-dose steroid treatment for myasthenia gravis. Case Reports in Ophthalmology 11: 534-539, No. 3, Sep 2020. 803516689 Available from: URL: http://doi.org/10.1159/000509527

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Editorial comment: A search of AdisBase, Medline, Embase and the WHO ADR database did not reveal any previous case reports of eye luxation associated with methylprednisolone.

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Reactions 21 Nov 2020 No. 1831