Endocrine Abstracts

A 44 year-old female presented to endocrine outpatient with 1-year history of 4 stone weight loss, heat intolerance, insomnia along with diplopia and sore and watery eyes. Her medical history includes IgG4 disease and rheumatoid arthritis, treated with prednisolone that had been stopped 6 months previously.

On examination, she was clinically hyperthyroid with a resting tremor, tachycardia and sweaty palms. Eye examination showed bilateral proptosis and chemosis worse on the left eye, diplopia and marked color vision loss in the left eye. She had a small, smooth palpable goitre.

Thyroid function tests revealed FT₄: 58.9 pmol/l TSH: <0.01 mU/l and FT₃: 13.2 pmol/l and positive TSH receptor antibodies. Treatment was commenced with carbimazole, propranolol and prednisolone for her ophthalmopathy. Urgent MRI of the orbits showed symmetrical enlargement of the extra ocular muscles and crowding of orbital apices, requiring urgent ophthalmology review and referral for external beam radiotherapy (EBRT).

She underwent urgent orbital decompression of the left eye as her vision deteriorated to light perception only. A repeat CT of the orbits following her operation still showed marked bilateral proptosis and crowding of the orbital apices with no improvement in her vision, so further decompression was performed to both eyes but this was delayed as she had uncontrolled thyrotoxicosis, which required admission for conversion of carbimazole to propylthiouracil and intravenous steroids. She had significant improvement of her visual acuity postoperatively.

Thyroid MDT discussion subsequently recommended definitive treatment for her Grave’s disease with a total thyroidectomy, as she was still requiring very high doses of carbimazole and radioiodine is contradicated due to the severe ophthalmopathy. She also had EBRT to stabilize her ophthalmopathy.

This case of severe Graves’ ophthalmopathy refractory to steroids, complicated by fluctuating thyroid control, highlights the importance of a multidisciplinary approach to avoid severe life-changing complications such as blindness, which can happen rapidly and potentially non reversible if delayed.