Endocrine Abstracts

Introduction: Ophthalmopathy is the most common extrathyroidal manifestation of Grave’s disease, with 3–7% evolving to Dysthyroid Optic Neuropathy (DON), which requires urgent treatment to avoid permanent or progressive visual loss. We describe two cases of DON evaluated at Endocrinology and Metabolism Service of Paraná (SEMPR).

Case 1: Male, 70 years old, previously diagnosed with hypertension, type 2 diabetes with insulin use, microvascular complications and cataracts (corrective surgery 8 years before). Presented with 1 week history of visual loss, conjunctival hyperemia and bilateral periorbital edema to the ophthalmologist, treated with photocoagulation on the left eye for diabetic retinopathy. Progressive visual loss persisted, and the patient was admitted to the hospital for evaluation after NMR of the orbits was compatible with Grave’s ophthalmopathy (bilateral periorbital muscle swelling). Endocrinology was consulted and laboratory showed TSH 0.00 mUI/ml (0.35–4.94), free T4 1.8 ng/dl (0.7–1.48), total T3 133.03 ng/dl (58–159) and TRAb 6.66 U/l (<1.75); clinical evaluation demonstrate a CAS of 6, with visual acuity 20/200 on right eye and 0 on left eye. Pulse therapy with 1 g/d methylprednisolone was initiated, for 3 days, alongside with thiamazole 10mg/day. Patient was discharged for ambulatory treatment with 500mg methylprednisolone per week. Visual acuity improved to 20/60 and 20/160 at 3 g cumulative dose for right and left eye respectively, and 20/60 and 20/40 at 6 g, with a CAS of 3.

Case 2: Women, 44 years old, Grave’s disease for 7 years in use of thiamazole 30 mg/day for the past 2 years reached our service with thyrotoxicosis symptoms and progressive visual loss for the past 2 years. Clinical evaluation revealed diffuse goiter, bilateral proptosis of 24 mm, divergent strabismus, CAS 1 (palpebral edema). Laboratory evaluation showed TSH<0.005 U/l, total T3 133.73 ng/dl and free T4 1.87 ng/dl. Ophthalmology consultation showed reduced visual acuity bilaterally (20/400), lagophthalmos, diffuse keratitis, optic disc hypoplasia and important atrophy of the pigmented cells of retina. Pulse therapy with 1gr methylprednisolone a day was initiated, for 3 days, but without improvement, patient was referred for surgical decompression of the optic nerve. Improvement of the visual acuity was referred by the patient on the second post operatory day.

Conclusion: In order to prevent permanent visual loss, DON must be diagnosed and treated aggressively. Patient 1 showed improvement, but is still on activity, with a planned 8gr of cumulative dosing and reevaluation. Patient 2, probably because of the delay reaching proper treatment, needed decompressive surgery.