Definitions of the classification of therapeutic evidence (Class I–IV), and strength of recommendations (A, B, C, U) are provided at the end of the "Major Recommendations" field.
Are Cholinesterase Inhibitors, Corticosteroids, or Other Immunosuppressive Agents Effective in Improving Visual Symptoms in Ocular Myasthenia?
Recommendations
Given the absence of evidence, it is not possible to make any evidence-based recommendations regarding the effects of cholinesterase inhibitors, corticosteroids, or other immunosuppressive agents in improving the symptoms of ocular myasthenia.
Are Cholinesterase Inhibitors, Corticosteroids, or Other Immunosuppressive Agents Effective in Reducing the Risk of Progression from Ocular to Generalized Myasthenia Gravis (MG)?
Recommendations
For patients with ocular myasthenia, the evidence does not support or refute the use of corticosteroids and/or azathioprine to reduce the risk of progression to generalized MG (Level U). The decision to use such agents should be weighed against the potential for harmful side effects of these medications. Furthermore, it is not possible to make any evidence-based recommendations with regard to the question of whether cholinesterase inhibitors have any effect in reducing the risk of progression to generalized MG. Recommendations cannot be made because of an absence of evidence.
Definitions:
Classification of Therapeutic Evidence
Class I: Prospective, randomized, controlled clinical trial with masked outcome assessment, in a representative population. The following are required: a) primary outcome(s) clearly defined; b) exclusion/inclusion criteria clearly defined; c) adequate accounting for dropouts and cross-overs with numbers sufficiently low to have minimal potential for bias; d) relevant baseline characteristics are presented and substantially equivalent among treatment groups or there is appropriate statistical adjustment for differences.
Class II: Prospective matched group cohort study in a representative population with masked outcome assessment that meets a–d above OR a randomized controlled trial (RCT) in a representative population that lacks one criteria a–d.
Class III: All other controlled trials (including well-defined natural history controls or patients serving as own controls) in a representative population, where outcome is independently assessed, or independently derived by objective outcome measurement.*
Class IV: Evidence from uncontrolled studies, case series, case reports, or expert opinion.
*Objective outcome measurement: an outcome measure that is unlikely to be affected by an observer's (patient, treating physician, investigator) expectation or bias (e.g., blood tests, administrative outcome data).
Classification of Recommendations
A = Established as effective, ineffective, or harmful for the given condition in the specified population. (Level A rating requires at least two consistent Class I studies.)
B = Probably effective, ineffective, or harmful for the given condition in the specified population. (Level B rating requires at least one Class I study or at least two consistent Class II studies.)
C = Possibly effective, ineffective, or harmful for the given condition in the specified population. (Level C rating requires at least one Class II study or two consistent Class III studies.)
U = Data inadequate or conflicting; given current knowledge, treatment is unproven.
