Comprehensive Eye Exams Key for MG-Related Vision Changes

Physicians should administer a comprehensive screen for autoimmune retinopathy as soon as it is suspected in patients with myasthenia gravis (MG) to prevent vision impairment, emphasized investigators in BMC Ophthalmology.¹

“Previous studies showed a higher frequency of concurrent autoimmune disease in patients with MG...,” the authors wrote. “However, very few cases on MG patients complicated with AIR [autoimmune retinopathy] have been reported in the previous literature.”

For the retrospective observational case series, they used a combination of studies found in PubMed and data on patients referred for care at the Department of Ophthalmology, Xinhua Hospital in Shanghai, China, from 2022 to 2024. Data were collected on visual acuity, intraocular pressure, anterior segment examinations by slit-lamp microscope, ultra-widefield fundus photography, optical coherence tomography, static perimetry, and electroretinography. Among the 7 patients included in this analysis, 6 were female patients, and the mean (SD) overall patient age was 41.29 (15.22) years.

Of the 7 patients included, 5 had thymoma, and the remaining 2 patients had no tumor. In addition, in 6 of the 7 cases, an MG diagnosis preceded an autoimmune retinopathy diagnosis. For the remaining individual patient, simultaneous diagnoses were made. The patients included in the study had these symptoms of autoimmune retinopathy: blurred vision and shadows, color discrimination and central vision impairment, floaters, night blindness, painless vision loss, photophobia, vision loss, and visual field constriction.

Upon fundus examination—a test that looks at the back of the eye and which is often used as a barometer of overall health, capable of diagnosing illness and injury^2,3—diffuse pigmentary retinopathy and retinal atrophy were seen. Drilling down, the following were seen in both eyes across the patients: hyperpigmentation, vascular attenuation, retinal pigmentary changes, parafoveal retinal pigment epithelial flecks, narrowing of peripheral retinal vasculature/mild pallor of optic discs/changes in retinal pigment epithelium, and diffuse pigmentary retinopathy/vitreous inflammation.

Electroretinography found rod and cone dysfunction. Specifically, the investigators saw that there were reductions in cone and rod responses, no recordable responses, severe dysfunction, and 1 patient who had preserved right-eye function but reduced left-eye response. Fundus autofluorescence found hypo-autofluorescence in the posterior pole, hypo-fluorescence encroaching onto the macula, diffuse granular defects, diffuse granular defects with pigment spots, and pigment spots without leakage or increased vascular fluorescence.

Antiretinal antibody testing determined the presence of several antiretinal antibodies, “confirming the diagnosis of autoimmune retinopathy,” the authors wrote. The antibodies they saw were against ENO1, enolase, aldolase, pyruvate kinase M2, 55-kD, 98-kD, interphotoreceptor retinoid-binding protein, glyceraldehyde-3-phosphate dehydrogenase, arrestin, and 58-kDa and 60-kDa proteins.

The 7 patients were put on a variety of immunosuppressive therapies or medication plus surgery for their myasthenia gravis, and all of their symptoms improved following treatment. These therapies encompassed the following and were individualized per patient:

• Steroids, azathioprine, tacrolimus, cyclosporine, and thymectomy
• Steroids, tacrolimus, and rituximab
• Steroids, pyridostigmine, azathioprine, plasmapheresis, thymectomy, and irradiation
• Plasmapheresis, thymectomy plus irradiation, and photodynamic therapy
• Steroids, plasmapheresis, and thymectomy plus irradiation
• Plasmapheresis and thymectomy plus irradiation
• Steroids, plasmapheresis, intravenous immunoglobulin, mycophenolate mofetil, and thymectomy

However, according to the autoimmune retinopathy findings, prognoses remained poor. Among the patients who experienced a decline in eye function in both eyes, light perception was reduced or eye function declined to this level and hand motion—meaning the patient has very low visual acuity and cannot even count fingers⁴—was the highest level of visual acuity. One patient had stable eye results. The remaining patient developed choroidal neovascularization in the left eye.

“Due to the rarity of [autoimmune retinopathy] cases, currently no standardized criterion of diagnosis, treatment, and serologic detection has been established,” the authors explained. “Detection of characteristic fundus abnormalities and exclusion of genetic retinopathy are needed.”

Therefore, based on their findings, they recommend a comprehensive eye exam for patients living with MG who experience vision loss, as this diagnosis can be challenging due to the symptom overlap between MG and autoimmune retinopathy. It’s even possible for clinicians to miss autoimmune retinopathy in their assessment.

Still, there are limitations on these findings. Retinal pigmentosa could not be ruled out despite the use of next-generation sequencing. There also are no clear established roles for certain antiretinal antibodies in autoimmune retinopathy, as some of these are present in both retinal pigmentosa and autoimmune retinopathy. “Further research is warranted to investigate the clinical validity of [antiretinal antibodies] or other biomarkers for the diagnosis of [autoimmune retinopathy],” they explained.

References

1. Chen Y, Zhang Y, Luo J, et al. Autoimmune retinopathy in patients with myasthenia gravis: cases series and literature review. BMC Ophthalmol. 2025;25(1):521. doi:10.1186/s12886-025-04357-5
2. Fundoscopy (ophthalmoscopy). Cleveland Clinic. Updated March 12, 2025. Accessed October 20, 2025. https://my.clevelandclinic.org/health/diagnostics/fundoscopy-ophthalmoscopy
3. Fundoscopic/ophthalmoscopic exam. Stanford Medicine. Accessed October 20, 2025. https://med.stanford.edu/stanfordmedicine25/the25/fundoscopic.html
4. Ang B. Visual acuity. Vision and Eye Health. January 15, 2024. Accessed October 20, 2025. https://www.vision-and-eye-health.com/visual-acuity/