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 or an inadequate trial of pyridostigmine (where inadequate is defined as a trial in which the dosage was titrated to neither efficacy [MMS] nor adverse events that did not resolve with the addition of a selective muscarinic antagonist)
• 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) > 2 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 > 30kg/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