Presentation
Bilateral proptosis, preseptal swelling and reddening, and orbital pain with a clinical history of Graves disease.
Patient Data
Remarkable and diffusely increased thickness of extraocular muscles, more prominently the inferior and medial rectus muscles, orbital apical crowding with impression on optic nerve sheath complex in both sides, and also remarkable bilateral proptosis.
There is also increased orbital fat content and relatively enlarged lacrimal glands with prolapse of the gland. Preseptal and lideyelid soft tissue swelling and anterior bulge. Some foci of fluid and thick mucosa in related paranasal sinuses are also noted.
Based on the laboratory exam findings, the patient is suffering from Graves disease.
Case Discussion
Thyroid eye disease or Graves ophthalmopathy is an autoimmune disease that activates orbital fibroblasts and has two main stages, early inflammatory and late fibrotic, and mostly involves the orbital extraocular muscles, fat, and related soft tissues and lead to proptosis and compression on the optic nerve due to enlarged extraocular muscles, especially within orbital apex which has limited space in comparison with other parts of the orbital cavity. The diagnosis of the disease is based on laboratory findings.
The imaging has a pivotal role in thyroid eye disease evaluation specifically in early diagnosis of clinically atypical cases, plan of surgery or medical treatment, and differentiation from other causes of proptosis. The MDCT scan and MRI are the main and more practical imaging modalities for detection of thyroid eye disease orbital cavity abnormal findings, stages of the disease.
Increased STIR signal intensity within extraocular muscles can detect the early inflammatory or active stage of the disease and non-contrast orbital MDCT can precisely depict the size of the extraocular muscles, orbital apex crowding, and optic nerve compression due to enlarged muscles. The inferior rectus muscle is the most common extraocular muscle involved in this disease but the enlarged superior rectus muscle-levator palpebral muscle complex is more predictive for compressive optic neuropathy.
The treatment of thyroid eye disease must be individualized based on the stage of the disease and main symptoms of the patient and includes, providing euthyroid state, smoking quit, selenium antioxidant, oral or intravenous steroids, immune modulation drugs, orbital radiation, and in case of unsuccessful medical treatment surgical decompression surgery must be done.
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