Endocrine Abstracts

Generally, after an initial active phase TED rarely reactivates. However, epidemiological evidence is scant. The following cases highlight the propensity for Graves’ orbitopathy to reactivate many years later.

Case 1: A 69-year-old woman had Graves’ disease aged 29, and was reviewed in the TED clinic (ophthalmology, rheumatology and endocrinology), with reactivation of orbitopathy 40 years after initial disease. She was an ex-smoker, had hypertension and previous TIA. Her aunt and daughter had autoimmune thyroid disease. She underwent radioiodine therapy (RAI) at age 34 and her TED symptoms had settled without intervention. Currently, she reported six months of progressive proptosis, diplopia and retrobulbar ache. There was conjunctival injection, eyelid oedema and restriction. The patient was clinically and biochemically euthyroid on levothyroxine. Her TSH receptor antibody (TSHRAB) titre was >30 IU/l (NR <0.4). CT imaging identified tendon sparing extraocular myopathy. Left sided visual acuity and colour perception were reduced. Ocular motility was restricted. IV methylprednisolone was commenced with oral rituximab and mycophenolate. Orbital decompressive surgery was planned if there was no adequate clinical improvement.

Case 2: An 89-year-old woman was seen during her third relapse of TED. Orbitopathy occurred at age 58 and 77. At age 77 she had optic neuropathy and was treated with IV glucocorticoid and bilateral orbital decompression. Most recently she presented with vision loss in the right eye, reduced ocular motility and proptosis. She was clinically and biochemically euthyroid on levothyroxine. TSHRABs were 8.5 U/l. MRI imaging showed tendon sparing extraocular myopathy. She was managed with intravenous glucocorticoid, methotrexate, ciclosporin and rituximab. Reporting worsening of vision between doses of glucocorticoid, she underwent repeat bilateral orbital decompression with subsequent radiotherapy. Her vision improved, with ongoing horizontal diplopia.

Conclusion: This highlights the potential for late recurrence of TED; further epidemiological data is needed.