PSAT352 A Case Report: Unilateral Graves’ Ophthalmopathy in Euthyroid Patient
Authors: Eid Mennaallah , Vargas-Jerez Julia , Zahra Tasneem 
Published: November 2022

Abstract

Introduction
Graves’ Ophthalmopathy is an immune mediated inflammation in orbital and retroorbital tissues, occurs mainly with hyperthyroidism,10% with euthyroid and rarely with hypothyroidism, more frequently in females(1).
Thyroid-stimulating hormone (TSH) receptor (TSHR) is the main auto-antigen, expressed in the thyroid gland, adipocytes and fibroblasts. It is aligned with insulin-like growth factor 1 (IGF-1) receptor. T cells activate TSHR and IGF-1 receptors and initiating a retro-orbital inflammation and accumulation of hydrophilic glycosaminoglycans (GAG)(2).

Case
46 yo, Hispanic obese male with history of type 2 DM and HLD, non-smoker, non- alcoholic, no illicit drugs. Family History of DM, no allergy,Home medications: Alogliptin benzoate 25mg/day, Metformin 1000mg twice/day and atorvastatin 10mg/day. Ophthalmology checkup 2 months before; visual acuity of 20/30, B/L nasal pterygium, no Diabetic retinopathy. Normal TSH (0.56ulU/ml) 6 months before. He presented to the Emergency department with 3 days of progressive redness, puffiness, photophobia and pressure like sensations in left eye, denied palpitations, change in bowel movements, weight loss/gain, heat/cold intolerance, fever, vomiting, headache, motor weakness, sensory loss. General examination alert, orientated x3,ABP 130/60, HR 75BPM, afebrile(98.4 F), BMI 37.56kg/m2, no tremors, no thyromegaly, normal heart, lung, abdomen examinations, no edema. Left eye conjunctival injection, proptosis, decrease visual acuity 20/60 and color vision, restricted eye movements, relative afferent pupillary defect, optic Neuropathy. Right eye nasal Pterygium and normal fundus examination. Laboratory findings; normal TSH 1.4ulU/ml, FT4 1.2ng/dl, FT3121ng/dl, High TSHR antibody4.69IU/L (normal less than 1.75IU/L), Thyroid peroxidase antibody 363IU/ml (normal less than 34.9IU/ml) and Thyroid stimulating immunoglobulin 3.55 IU/L (normal less than 0.55IU/L). Normal CBC, GFR, negative C-ANCA, P-ANCA antibodies. CT orbit showed marked exophthalmoses, prominence of infraorbital fat, thickening of inferior and medial rectus muscles of left eye. He was kept on IV Solumedrol 250mg Q 6hrs for 3 days, artificial tears. Symptoms improved, was discharged on tapering oral steroid starting with prednisone 80mg daily. Follow up after 5 days reported marked improvement of symptoms with slight proptosis, no optic neuropathy.

Conclusion
Graves’ Ophthalmopathy can occur in euthyroid patients. Presents mainly with bilateral eye affection, few cases have unilateral eye affection. IV or oral Steroid is the Main treatment of Graves’ ophthalmopathy with local eye measures and management of thyroid disease. Other options are teprotumumab (IGF-1 receptor Inhibitor), and rituximab or orbital decompression surgery/external orbital radiation. Close follow up is recommended as orbitopathy precedes hyperthyroidism in 20%of cases(3,4).

References
1-Kersten R. American Academy of Ophthalmology Section 7, Orbit, Eyelids and Lacrimal System 2004-2005: 48-56.
2-Bahn RS. Graves’ ophthalmopathy. N Engl J Med 2010; 362: 726. 3-Douglas RS, Kahaly GJ, Patel A, et al. Teprotumumab for the Treatment of Active Thyroid Eye Disease. N Engl J Med 2020; 382: 341. 4-Zang S, Ponto KA, Kahaly GJ. Clinical review: Intravenous glucocorticoids for Graves’ orbitopathy: efficacy and morbidity. J Clin Endocrinol Metab 2011; 96: 320.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.