Efficacy of Prednisone In the Treatment of Ocular Myasthenia

The purpose of this study is to learn two things about prednisone in patients with ocular
myasthenia. The first thing we aim to learn is whether or not prednisone is effective in
improving the symptoms of double vision and drooping eyes that are experienced by patients
with ocular myasthenia. The second thing we aim to learn is whether we can find a dose of
prednisone that is well tolerated and safe. The overall goal is to find out whether a dose of
prednisone that is safe and well tolerated is also effective in improving the symptoms of
ocular myasthenia.

After completing screening assessments to confirm eligibility, all participants will receive
treatment with pyridostigmine. If a participant's symptoms do not resolve within the first
month while being treated with pyridostigmine, they will be randomized to receive prednisone
or placebo. The amount of study medication a participant receives will depend on how their
symptoms respond to the medication and if they experience any side effects.

After four months, participants that continue to have symptoms of ocular myasthenia and do
not have side effects will receive open label high dose prednisone. Participants that no
longer have symptoms will taper their dose of study drug in a double-blind fashion.

Inclusion Criteria:

- Weakness confined to the extra-ocular muscles, eyelid levator and eye closure with an
ocular-QMG1 score ≥ 1

- At least one of the following combinations of abnormal diagnostic testing: a) Elevated
acetylcholine receptor antibody titers, (b) Abnormal repetitive nerve stimulation (>
10% decrement following slow repetitive nerve stimulation) of any nerve-muscle pair,
(c) Abnormal jitter on single fiber or concentric needle electromyography in any
muscle, (d) Positive ice test and brain MRI that demonstrates no central nervous
system pathology that mimics ocular myasthenia, or (e) Positive Tensilon test and
brain MRI that demonstrate no central nervous system pathology that mimics ocular
myasthenia

- Either no prior treatment with pyridostigmine, or participant has persistent ocular
symptoms that are functionally limiting or troublesome despite treatment with
pyridostigmine.

- Age 18 years or older, male or female

- Capable of providing informed consent and complying with study procedures

- Identifiable primary care physician to assist with management of medical complications
that may arise as a consequence of steroid therapy

- Willing to be randomized to a trial of prednisone or placebo if symptoms respond
inadequately to pyridostigmine.

Exclusion Criteria:

- Disease duration (time since symptom onset) > 5 years

- Treatment with prednisone or other corticosteroids within 90 days of randomization

- Treatment with azathioprine, cyclosporine, mycophenolate mofetil or other immune
suppressive medication since onset of MG unless dosages of these medications and/or
duration of therapy with these medications are clinically insignificant in the
judgment of the PI

- Intravenous immunoglobulin or plasma exchange within 90 days of randomization

- Prior thymectomy or history of thymoma

- Contraindication to steroids (poorly controlled diabetes, glaucoma or hypertension,
history of prior steroid intolerance, obesity [BMI > 39.9kg/m2] or a history of
osteoporotic fracture)

- Pregnant or lactating

- Renal failure, active thyroid or hepatocellular disease, chronic infection, poorly
controlled cardiac disease, unstable psychiatric illness, untreated major depression
or any other illness that would, in the opinion of the treating neurologist, make it
unsafe for the patient to participate in the trial

- Receipt of another investigational drug within 30 days of Screening