Orbit Case #4 - Troubling Double

This symposium has been created to highlight the surgical aspects of our field and to educate Neuro-ophthalmologists and trainees through the presentation and discussion of complex surgical Neuro-ophthalmic case scenarios.

Orbit Case # 4 “Troubling Double” Andrea A. Tooley, MD Mayo Clinic Rochester, MN Presentation • 27 year old man presents with right ptosis, left proptosis, and diplopia • POH: Myopia • SH: Works as software analyst, no drug or alcohol use. Had COVID vaccine, most recently in 8/2021. Does not smoke. • FH: No FH of thyroid disease. • ROS: Negative for fevers, headaches, neck, joint pain, CP, SOB, GI symptoms or urinary symptoms. No new rashes. • Allergy: Catfish with breathing issues. Initial workup • EOM full • Variable esotropia and hypertropia measurements • pupils equal and reactive • 4mm proptosis left eye on Hertel • + Cogan Lid Twitch, normal ice pack test, no fatigability with upgaze • Otherwise eye exam normal Labs • TSI: 2.0 (normal <0.02) • Negative/Normal Ach receptor binding antibodies, Thyrotropin receptor antibody, GQ1b, anti-neutrophil cytoplasmic antibodies, PR3, ACE, Myasthenia Gravis, QuantiFERON, Syphilis, CBC. Plan: • Given NO pain, non-revealing labs, was started on 60 mg prednisone daily and had complete resolution of diplopia. • Right ptosis also improved (due to left retraction?) • Given elevated TSI, could this be thyroid eye disease??