Endocrine Abstracts

Thyroid eye disease (TED) is clinically evident in 25–50% of patients with Graves’ disease and 3–5% of cases develop severe eye disease. We present a case of very aggressive TED.

A 46-year-old gentleman developed graves thyrotoxicosis and was blocked and replaced with carbimazole and thyroxine. He continued to smoke 20 cigarettes/day despite several advises.

He developed marked exophthalmos (L>R), chemosis, with reduced convergence. He was commenced on prednisolone. MRI Orbits showed the medial, inferior and superior recti were enlarged on the left side but no significant compression at the conus. On the right the superior and inferior recti were mildly dilated with well-maintained conus.

He developed two acute episodes of compressive optic neuropathy and proptosis particularly affecting the left eye. He was treated with intravenous methylprednisolone. His vision improved and the optic nerve heads that were initially swollen with hyperemia began to settle.

Azathioprine was commenced. Despite this his left optic nerve head became increasingly swollen. His left eye was touching the lens of his glasses.

CT Orbits showed proptosis, the eyes appeared to have convergent squint. Thickening of conal musculature on both eyes (L>R), the abnormality affecting the inferior, medial and superior recti. Towards the optic apex the muscular thickening crowding the optic nerve.

He had left orbital decompression and his optic neuropathy resolved. A few days later he developed pigment epithelial detachment in the left eye as a result of polypoidal choroidal lesion. This was treated with photodynamic therapy.

He was clinically and biochemically euthyroid. His vision in left eye is poor 2/60 (6/18 with pinhole), has little vision in right eye 6/12 and restricted movements in all directions.

This case illustrates the difficulties with managing TED, importance of cessation of smoking and highlights the options of surgical management and photodynamic therapy in aggressive conditions.