Endocrine Abstracts

Introduction: The thyroid eye disease (TED) is an autoimmune disorder. Diagnosis is based on recognition of clinical features and may be supported by serologic tests of thyroid function, immune testing, and orbital imaging. Clinical orbital signs include eyelid retraction, proptosis, compressive optic neuropathy signs, eyelid erythema, chemosis, caruncular edema, and restrictive strabismus. The laboratory tests include thyroid-stimulating hormone-receptor (TSH-R) antibody, thyroid-stimulating immunoglobulin (TSH), thyroid-binding inhibitory immunoglobulin (TBII), and anti-microsomal antibody. The typical feature in orbital imaging is enlargement of extraocular muscles. The majority of TED patients have hyperthyroidism (90%), 6% of the patients are euthyroid, 1% have hypothyroidism, and 3% are affected by Hashimoto’s thyroiditis at the time of diagnosis. Strabismus may occur in 15% of all patients with TED. Diplopia is a common symptom of the strabismus, which can interfere with the daily activities of the patient. Strabismus and diplopia management remains challenging.

Case presentation: We present a case of 42 y/o male who was referred to our endocrine department in February of 2024 by the ophthalmologist. Patient had complaints of diplopia, internal strabismus and eye movement restriction, periodic headache and palpitations since 10.2023. He was diagnosed with autoimmune thyroiditis at that time. MRI done in 10.2023 revealed lateral rectus muscle swelling and increased thickness. Unfortunately, patient did not receive appropriate assessment and recommendations. We ordered laboratory tests, which revealed increased FT3, normal TSH, FT4, patient was instructed to initiate IV methylprednisolone infusions and selenium intake. After 3 weeks, on the follow up visit, patient demonstrated significant clinical improvement, the degree of strabismus and diplopia, swelling and facial redness were also decreased. FT3 normalized, TSH and FT4 remained within normal limits. Patient is given corresponding recommendations to continue his treatment and further diagnostic assessment.

Conclusion: Abnormalities in thyroid hormonal tests and/or the presence of thyroid specific antibodies help to support the diagnosis, but they are not essential, and their absence does not exclude the diagnosis. Systemic glucocorticosteroids, rituximab, and tocilizumab have been shown to be effective in improving ocular motility and diplopia in these patients. Strabismus related to thyroid eye disease presents many challenges to the ophthalmologist. Management of these patients is classified into non-surgical and surgical approaches. Multidisciplinary approach, appropriate patient selection and available therapies guide the treatment.