Endocrine Abstracts

Background: Graves’ orbitopathy (GO) is one of the extrathyroidal manifestations of Graves’ disease (GD), an autoimmune condition characterised by increased antibodies against TSH receptors (TRAb). The prevalence of GO among patients with GD is up to 40%. Moderate-to-severe, sight-threatening and sometimes even mild GO have significant negative impact on patient’s quality of life (QoL). Various clinical presentations of GD itself, evaluation and timely management of GO can oftentimes become challenging resulting in delayed treatment and worsening of patient’s QoL. Here, we describe a case of moderate-to-severe form of GO with delayed treatment.

Case: A 57-year-old woman first noticed right eye bulging about 2.5 years ago which she relates to an emotional stress. She was referred to an endocrinologist. Laboratory investigations revealed: TSH=0.06 µIU/ml, FT4=1.1 ng/dl, FT3=3.4 pg/ml, Anti-TPO=1300 IU/ml, TRAb=3.47 IU/l. Despite GD, antithyroid drugs were not started. Although no treatment was provided, after 9 months, patient’s symptoms resolved spontaneously and the laboratory tests revealed euthyroidism. Another year later, patient again suffered an emotional stress following which she developed unilateral right-sided exophthalmos. Laboratory tests revealed elevated TRAb of 1.78IU/l with euthyroidism (TSH=1.64 µIU/ml). On thyroid ultrasound total volume of the gland was 5.1 cm³ with heterogeneous structure and moderately increased vascularity, no nodularity. Orbital MRI showed infiltration of the right eye inferior and medial recti muscles. Activity and severity of GO was assessed with CAS=5 and NOSPECS. The diagnoses of euthyroid GD and unilateral active moderate-to severe GO were established. However, relevant treatment was not initiated even at this point. 6 months later, she presented at our hospital with right-sided exophthalmos, diplopia, and eye movement restriction with upward and lateral gaze. Currently, thyroid function tests again showed euthyroidism with elevated TRAB (TSH=1.61 µIU/ml, FT4=12.1 ng/dl, FT3=5.48 pg/ml, TRAb=1.43 IU/l). Repeated assessment of GO now revealed inactive moderate-to severe form. At the same time, patient’s daily activities are affected and QoL severely reduced. Patient was referred to an ophthalmic surgeon and strabismus surgery is now being considered in order to restore binocular single vision.

Conclusions: As our case demonstrates, it is crucial to recognise and treat active forms of GO independent of the thyroid function. Delayed treatment can result in irreversible changes in the orbits that can only be managed by surgery, simultaneously severely worsening patients’ quality of life.