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Show Journal of Naim- Oplulmlnmlogy 19( 1): 54- 55, 1999. © 1999 Lippincoll Williams & Wilkins, Inc., Philadelphia A Sneak Peek: A Case of Early Thyroid Eye Disease Gregory S. Komorsky, D. o. A 47- year- old woman noted intermittent swelling in the left periorbital area beginning in September 1997. The swelling was associated with an occasional pressure sensation in and surrounding the left orbit. Visual acuity was normal, as was motility. Intraocular pressure was 15 mm Hg OU. Findings in slit lamp and dilated fundus Manuscript received July 7, 1998; accepted December 2, 1998. From the Division of Ophthalmology, the Cleveland Clinic Foundation, Cleveland, Ohio. Address correspondence to Gregory Kosmorsky, D. O, Cleveland Clinic Foundation A- 31, 9500 Euclid Ave., Cleveland, OH 44195- 5024. examinations were unremarkable. Hertel exophthalmom-etry with a base of 100 was 15 OU, and retropulsion was normal. No diagnosis could be made, and she was referred for further evaluation. When interviewed, her sister volunteered that the patient's left eyelid seemed to stay open when she took a nap. She had been feeling progressively more tired during the past year and had experienced episodes of perspiring that she attributed to menopause. She described no palpitations, skin or voice changes, or hair loss. The salient features of her examination was the presence of lid lag on downgaze, mild lid retraction, and lateral peeking of the temporal aspect of the left upper lid ( Fig 1). Laboratory evaluation included T4 and thyroid- stimulating hormone ( TSH) testing. The FIG. 1. In downgaze, the patient exhibits definite lid retraction of the left eye. 54 EARLY THYROID EYE DISEASE 55 FIG. 2. There is subtle enlargement of the left levator/ superior rectus complex on the left. T4 result was within normal limits, whereas the TSH test result was less than 0.02 mIU/ 1 ( normal range, 0.40- 5.50 mIU/ 1) indicating early thyroid dysfunction. Orbital CT scanning showed subtle enlargement of the left superior rectus- levator complex, consistent with early thyroid eye disease ( Fig 2). No other evidence of extraocular muscle enlargement could be discerned. This case illustrates that the ocular and imaging findings of early thyroid eye disease may be subtle. Typically, the inferior rectus muscle is the first to be involved in thyroid eye disease, followed by the medial rectus, superior rectus, lateral rectus, and finally, the obliques. However, any muscle may be the first target of the inflammatory process that characterizes Graves' disease. The laboratory evaluation was helpful in this case, but it is not always revealing. J Neuro- Ophthalmol, Vol. 19. No. I. 1999 |
