SAT-486 A Case of Severe Thyroid Ophthalmopathy Requiring Emergency Orbital Decompression and Total Thyroidectomy

Introduction:Graves is the most common cause of hyperthyroidism (5). In graves orbitopathy (GO) the activation of T-cells causes fibroblast proliferation and accumulation of hydrophilic glycosaminoglycans, causing osmotic muscle swelling and inflammation resulting in increased orbital pressure (5). Mild GO is managed with selenium, moderate GO with high dose steroids (methylprednisolone) (2). Rituximab is an alternative treatment (4). Severe GO is treated with orbital decompression surgery (2). Case presentation:A 43-year-old incarcerated male with a history of Graves disease of 4 years,on methimazole, dry eye syndrome, and proptosis, presented to the ED with 5 days of increasing right eye pain, decreased vision and inability to close his right eye. In the ED he had increased intraocular pressure. Glaucoma was considered and the patient was treated with acetazolamide. His ocular pressures improved slightly but vision did not correct. Labs revealed: TSH <.005, FT3 5.48, FT4 1.75, Alkphos 318, TPO Ab 153, TS immunoglobulin >500. Steroids were given but ineffective. Treatment with potassium iodide lowered FT3 to 2.18 and FT4 to 1.27. With continuing eye pain rituximab was started, but was not tolerated. Selenium was not considered due to the severity of GO. The patient was cleared for acute surgical decompression that successfully improved ocular symptoms. The patient’s GO was so severe that a total thyroidectomy was completed for long-term treatment, without complications. Discussion:In the setting of GO it has been shown that thyroglobulin passes to the orbit where autoantibodies cause inflammation, preventing correction even when hormone levels have been managed (3). Smoking is a known risk factor for GO, cessation is one of the first keys to management (2). A complete thyroidectomy is favored compared to radioiodine (worsens orbitopathy) or antithyroid drug therapy. Surgery has been shown to have a positive impact on the regression of GO Rituximab is a relatively safe and viable treatment that is superior to glucocorticoids or saline for patients with moderate to severe GO. (1).References:1 Regression of Ophthalmopathic Exophthalmos in Graves’ Disease After Total Thyroidectomy Indian Journal of Surgery. 2017;79(6):521–526 2.The 2016 European Thyroid Association/European Group on Graves’ Orbitopathy Guidelines for the Management of Graves’ Orbitopathy. European Thyroid Journal. 2016 Mar 2; 5(1): 9–26 3.Does autoimmunity against thyroglobulin play a role in the pathogenesis of Graves’ ophthalmopathy: a review. Clinical Ophthalmology (Auckland, NZ). 2015;9:2271–2276. 4. Rituximab in the Treatment of Thyroid Eye Disease: A Review. Neuro-Ophthalmology (Aeolus Press). 2015;39(3):109–115. 5. Thyrotropin receptor autoantibodies are independent risk factors for Graves’ ophthalmopathy J Clin Endocrinol Metab. 2006;91(9):3464.