Old Bottle, New Wine: Diplopia Sans Proptosis as the Sole Presentation of Thyroid Orbitopathy

Thyroid orbitopathy holds a dominant place in the list of causes for external ophthalmoplegia and is commonly accompanied by eye surface signs such as congestion, lacrimation, and proptosis. An elderly male presented to us with painless diplopia in the absence of proptosis, conjunctival congestion, tearing or irritative symptoms. He had bilateral complete external ophthalmoplegia. He was evaluated to have hypothyroidism with elevated anti-thyroid peroxidase antibodies. MRI revealed bulky extraocular muscles in a pattern of sparing of tendinous insertions, highly suggestive of thyroid orbitopathy. He was managed with IV steroid pulse and thyroxine supplementation with minimal improvement. Through this case report, we highlight an unusual presentation of thyroid eye disease in the form of isolated diplopia, in the absence of other usual eye signs. We also emphasize the characteristic typical neuroimaging signs, such as the ‘Coca Cola bottle’ sign, which strongly augments the diagnosis in an atypical setting.