A 77-year-old man was referred to the neuro-ophthalmology clinic at Tufts/New England Eye Center for bilateral optic nerve swelling.
Six months prior, the patient had reportedly sought evaluation from an outside neuro-ophthalmologist due to intermittent binocular double vision and fatigue, with no other symptoms. During this assessment, the patient exhibited a positive ice test and was consequently diagnosed with ocular myasthenia gravis. He was started on pyridostigmine, which effectively managed his double vision.
One month later, he presented to another outside ophthalmologist, reporting