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Case 397

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71-years-old male, former smoker, with a history of iodine radioablation in 2012 after being diagnosed with Graves'disease when he was 62-years-old. In follow-up at the endocrinology service, he complains of itching, burning and watery eyes. He has a glycated hemoglobin measurement of 6.1%. CT scan of the orbits was requested.

Analyzing the patient's images and data, it can be concluded that the most likely cause of the ocular signs and symptoms is:

a) Post ablation thyrotoxicosis

25%

b) Autoimmune reaction to ocular fibroblasts

25%

c) Maintenance of hyperthyroidism due to failure of radioablation therapy

25%

d) Orbitary celulitis

25%
   

Image Analysis 

Image 1: Ectoscopy of the patient, in which periorbital edema and bilateral conjunctival hyperemia are observed, in addition to strabismus converging to the left.

 

Image 2: CT of the orbits, axial view, with tracing of the interzygomatic line in blue. Under normal conditions, approximately 1/3 of the eyeballs is posterior to this line. In this patient, only the posterior wall of the eye makes contact with the line, which indicates ocular protrusion. In addition, it is possible to notice bilateral thickening of the rectus medial (red arrows) and lateral (yellow arrows) muscles.

Highlights:

  • - Graves' ophthalmopathy results from the activation of orbital fibroblasts by anti-TSH autoantibodies, which results in the production of edema and inflammation;

  • - The main signs and symptoms are: retraction and eyelid edema, proptosis, ocular hyperemia, irritating symptoms of the ocular surface and diplopia;

  • - Imaging tests can be useful in the differential diagnosis with other causes of proptosis and in the evaluation of periorbital tissues and optic nerve;

  • - Although orbitopathy can affect euthyroid patients, adequate control of the underlying thyroid disease is a protective factor for the orbital condition;

  • - Treatment consists of smoking cessation, use of lubricating eye drops, corticosteroid therapy in more severe cases and surgical approach when possible and necessary;

References

- Bahn RS. Graves‘ Ophthalmopathy. New England Journal of Medicine. 2010 Feb 25;362(8):726-738. DOI 10.1056/NEJMra0905750.

  • - Bahn RS, Heufelder AE. Pathogenesis of Graves' Ophthalmopathy. New England Journal of Medicine. 1993 Nov 11;329(20):1468-1475. DOI 10.1056/NEJM199311113292007.

  • - Kronenberg HM, et al. Williams Tratado de Endocrinologia. 1st ed.: Elsevier Professional; 2010.,.

  • - Bartalena L, Baldeschi L, Boboridis K, Eckstein A, Kahaly GJ, Marcocci C, Perros P, Salvi M, Wiersinga WM. The 2016 European Thyroid Association/European Group on Graves' Orbitopathy. Guidelines for the Management of Graves' Orbitopathy. European Thyroid Journal. 2016 March 2;5:9-26. DOI 10.1159/000443828.

Author

Luan Salvador Machado Barbalho, 5th year medical student at UFMG.

E-mail: luansmb8[at]gmail.com

Supervisor

Ana Rosa Pimentel de Figueiredo, ophthalmologist, adjunct professor at the Department of Ophthalmology and Otorhinolaryngology, Faculty of Medicine UFMG.

 

Júlio Guerra Domingues, radiologist, professor at the Department of Anatomy and Image at FM-UFMG.

E-mail: jgdjulio[at]gmail.com

Reviewers

Gustavo Vargas Borgongino Monteiro, Mirella Monique Lana Diniz, Marcela Chagas Lima Mussi, Melina Assunção Gomes de Araújo, Leandra Prates Diniz, Letícia de Melo Elias.

Acknowledgment

Aline Ferreira Zwetkoff, ophthalmologist at HC-UFMG, for all the help and consideration in building this case.

Translated by

Luan Salvador Machado Barbalho

 

Test question

(Medical Residence 2015 - Hospital Universitário Onofre Lopes - UFRN)

24-year-old woman with a history of bronchial asthma and celiac disease, using beclomethasone and formoterol via inhalation and a gluten-free diet, seeks medical attention due to complaints of palpitations, extremity tremors, insomnia and loss of 8 kg in the last 3 months. On physical examination, it shows: ACV - RCR without murmurs; FC: 118 bpm; PA: 140 x 70 mmHg; fine upper extremity tremors; exacerbated Achilles and patellar reflexes; important conjunctival hyperemia; bilateral chemosis and proptosis. Thyroid palpation was performed, with increased dimensions, fibroelastic consistency, without palpable nodules, without murmurs. In addition, the patient is eupneic, stained and oriented. The results of his laboratory tests were: TSH:

a) Oral propylthiouracil to administer radioiodine

25%

b) Oral propranolol to administer radioiodine

25%

c) Oral and in-house propranolol for thyroidectomy

25%

d) Oral prednisone and methimazole

25%

e)

25%
   

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