330 © Neuro-Ophthalmology the test is considered positive and can be discontinued. If no response is elicited, an dose of 4 mg edrophonium is given. If there is still no improvement, the final dose of 4 is given. Administering the drug in divided doses seems to cause fewer adverse eff However, many patients develop minor side effects (fasciculations, warmth, nausea) matter how it is given. When the ocular symptom is significant (such as complete py the end point (eyelid elevation) is often dramatic. However, 2 subtle deficit such as mal diplopia may require that other means be used to better define the end Point. Ma rod tests with prisms or diplopia fields may be performed before and after edrophoj (see Chapter 8). False-positive responses are rare. A negative test does not exclude diagnosis of MG, and repeat testing at a later date may be needed. An alternative to the Tensilon test is the neostigmine methylsulfate (Prostigmin) t This test is particularly useful in children and in adults without ptosis who may requit longer observation period for accurate ocular alignment measurements than that alk by edrophonium. Adverse reactions are similar to those with edrophonium. The frequent side effects are salivation, fasciculations, and gastrointestinal discomfort. Int muscular neostigmine and atropine are injected concurrently. A positive test prod resolution of signs within 30-45 minutes. The sleep test is a safe, simple office test that eliminates the need for Tensilon test in many patients. After having the baseline deficit documented (measurements of pt motility disturbance), the patient rests quietly with eyes closed for 30 minutes. The surements are repeated immediately after the patient “wakes up” and opens his or eyes. Improvement after rest is highly suggestive of MG. The ice-pack test is often helpful for diagnosing patients, but only if they have pt An ice pack is placed over lightly closed eyes for 2 minutes. Lmprovement of ptosis oc in most patients with MG (Fig 14-2). One exception is the patient with complete my thenic ptosis; the cooling effect may be insufficient to overcome the severe weakness these patients. Golnik K, Pena R, Lee A, Eggenberger ER. An ice test in the diagnosis of myasthenia gravis. Ophthalmology. 1999;106(7):1282-1286. ‘Odel JG, Winterkorn JM, Behrens MM. The sleep test for myasthenia gravis. A safe alternative to Tensilon. J Clin Neuroophthalmol. 1991;11(4):288-292. i Seybold ME. The office Tensilon test for ocular myasthenia gravis. Arch Neurol. 1986;43(8): 4 842-843. 57-year-old woman with myasthenia gravis presented with moderate, vat left ptosis improved after a 2-minute ice-pack test. (Courtesy of Kari C Goink.