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Ing is positive in approximately 75% of patients with generalized mg, but is positive in only 50% of patients with ocular mg. False positive are seen in lems, als and polyomyositis. viagra canada online   3. Single fiber emg:  the single fiber emg is highly sensitive for ocular myasthenia, with a sensitivity of 88-99%. This is a good diagnostic test for congenital myasthenia gravis. viagra cost   4. Sleep test:  the sleep test is a simple clinical test. buy viagra online The patient is asked to note if there is marked improvement in symptoms upon awakening. This can be done in the office if the patient is very sleepy!   5. Ice test:  this is also a simple diagnostic test that can be done in the clinic. It is highly sensitive and specific for mg. The ice test is useful for ptosis. An ice pack is applied to the affected upper eyelid for 10 minutes. A positive test is the improvement of ptosis by > 2mm or more. Laboratory tests 1. Serum anti-ach receptor antibody titer:  this assay measures three different anti-ach receptor antibodies found in mg: binding antibodies, blocking antibodies, and modulating antibodies. viagra no prescription overnight shipping Binding antibodies are present in 85- 90% of systemic mg patients, and 50% of ocular mg patients. When binding antibodies are negative, blocking and modulating antibodies are then tested. Although this test is relatively sensitive and specific for mg, 10% to 15% of patients with systemic mg will test negative, as will 30% to 50% of patients with ocular mg.   false positives occur in patients with immune liver disorders, thymoma without mg, lems, those with primary lung cancer and in a small percentage of older individuals. 2. Serum anti-muscle-specific kinase antibody titer: musk assays are used when anti-ach receptor antibody titers are negative but the clinician has a strong clinical suspicion for mg. viagra coupon   differential diagnosis the differential diagnosis for mg is vast. Due to its variability in presenting symptoms, mg can mimick many diseases. It is important to remember that the presence of pupillary abnormalites excludes the diagnosis of mg. Lambert-eaton myasthenic syndrome (lems) can be thought of as the opposite of mg. viagra without prescription The clinical features in lems include proximal muscle weakness and hyporeflexia with improvement of symptoms with repeated muscle stimulation. viagra no prescription overnight shipping Lems is caused by antibodies directed against presynaptic calcium channels. It is associated with small cell lung carcinoma. viagra free samples nz Since ptosis is the most common presenting symptom in mg, it is important to go through its differential diagnosis. Ptosis is defined as margin to reflex diameter 1 (mrd 1) of less than 2mm or an asymmetry of more than 2mm between eyes.   normal palpebral fissure (pf) vertical length is about 9mm, a ptotic lid has a pf < 9mm. Myasthenia gravis with ptosis has an extensive differential diagnosis. safed musli viagra This includes: an intracranial lesion, tumor, pituitary adenoma, aneurysm, fascicular. viagra without prescription Serving East Richmond, Queensborough, New Westminster, & Annacis Island since 1991.