Endocrine Abstracts

Grave’s orbitopathy typically presents with symptoms of proptosis and diplopia. It is an autoimmune condition of retro-orbital tissues. We present a case in which the management of orbitopathy has been complex and required escalation to immunosuppression and consideration of biological agents. A 34-year-old female presented with 2 weeks of diplopia. She had normal visual acuity with no past medical or family history. She never smoked. Thyroid eye disease was diagnosed, she was started on selenium and commenced on pulsed methylprednisolone. At the time thyroid function showed TSH<0.01 U/ml, FT4>65 ng/dl, FT3 45 ng/dl. TSH receptor antibodies were positive at 2.9 unit/ml (NR<0.4). She was commenced on Carbimazole 60mg and responded very quickly. 10 weeks into into her pulsed methylprednisolone course and despite biochemical euthyroidism she developed worsening visual acuity and colour vision and required bilateral orbital decompression. Post-operatively she was commenced on oral prednisolone 50 mg daily and mycophenolate, which was uptitrated to 1.5 g twice daily. Colour vision has recovered but she has restrictive strabismus in the left eye with visual acuity of 6/18 pinhole (6/9 unaided) and acuity in the right eye 6/18 pinhole (6/12 unaided). Prednisolone has not been weaned beyond 30 mg daily as the patient develops worsening diplopia at every such attempt. She remains biochemically euthyroid on block and replace regimen. Rituximab is being explored as second-line immunosuppressant. Thyroidectomy is considered; however, its role in euthyroidism with low antibody titres remains controversial. The management of Grave’s orbitopathy is complex. Sometimes it is difficult to predict the course of Grave’s ophthalmopathy from that of thyrotoxicosis and many of the treatments cause their own side effects. In severe cases of ophthalmopathy aggressive treatment is required for sight-saving measures. This case however highlights the importance of the multidisciplinary approach in managing severe cases to ensure early diagnosis and treatment.