To determine the proportion of ocular myasthenia gravis (OMG) patients with multiple autoantibody positivity and evaluate whether the presence of multiple autoantibodies is associated with an increased risk of progression from OMG to generalized myasthenia gravis (GMG).

Acetylcholine receptor (AChR) antibodies are found in approximately 50% of patients with OMG and are associated with an increased risk of the disease progressing to GMG. The relationship between the presence, type, and number of autoantibodies in OMG and the clinical course of the disease remains unclear.

We performed a retrospective, single-center chart review of all patients diagnosed with myasthenia gravis (MG) at Froedtert Hospital between January 1, 2016, and August 1, 2023. Clinical data were abstracted from electronic medical records to characterize patient demographics, disease features, treatments, and outcomes.

A total of 268 patients with a MG diagnosis were included. Among patients with three positive antibodies, a higher proportion developed generalized MG (26 out of 35, or 74.3%) compared with those with fewer or no antibodies. Among those with 0 antibodies, the distribution of patients who did and did not develop GMG is nearly even. Overall, 67.9% of antibody-negative patients did not develop GMG, while 67.9% of antibody-positive patients did develop GMG.

There was a statistically significant association between the number of positive antibodies and the development of generalized MG (p = 0.024), and Linear-by-Linear Association (p = 0.003). Patients with binding antibody positive were significantly more likely to start with or develop GMG (Chi-Square = 29.595, p < 0.001).

Across multiple analyses and outcome measures, antibody positivity—especially the presence of multiple antibodies—is strongly associated with higher likelihood of transformation to GMG.