Diagnostic accuracy and clinical utility of bed side tests versus laboratory tests in the diagnosis of ocular myasthenia

PURPOSE: To assess the diagnostic accuracy of forced eyelid closure test (FECT), ice pack test (IPT), repetitive nerve stimulation test (RNS), and acetylcholine receptor (AchR) antibody test in patients with suspected ocular myasthenia. To assess the clinical utility of AchR antibody test in predicting disease progression. METHODS: Retrospective cohort study of patients diagnosed with ocular myasthenia at a South-Indian neuro-ophthalmology tertiary eye clinic. Baseline characteristics; ocular myasthenia symptoms; results of FECT, IPT, RNS, and AchR antibody test; and progression time to generalized myasthenia (GM) over 36 months from the time of diagnosis were recorded and analyzed using receiver operator curve analysis, multiple logistic regression, and Kaplan–Meier survival analysis. RESULTS: FECT had a sensitivity of 96.7% (95% CI: 88.5–99.6) and a specificity of 75% (95% CI: 34.9–96.8). Combination of FECT and IPT, using the positivity of at least one test, increased the sensitivity to 98.3% (95% CI: 91–100), reducing the specificity to 50% (95% CI: 15.7–84.3), whereas using the positivity of both tests, we obtained a sensitivity of 71.7% (95% CI: 58.6–82.5) and a specificity of 100% (95% CI: 63.1–100). In the subset of patients with double negative RNS and AchR antibodies, the positive predictive value of combined FECT and IPT (double positive) was 100%. Patients who developed GM were more likely to have a positive AchR antibody test result (P = 0.001) CONCLUSION: Combined FECT and IPT (double positive) has high diagnostic accuracy even among patients with normal RNS and negative AchR antibodies. Despite low sensitivity, AchR-antibody test has a significant predictive value in disease progression.