56-year-old man with a history of laryngeal neoplasia, type 2 diabetes mellitus, ex-smoker and ex-drinker, diagnosed with hyperthyroid crisis. At that time he presented exophthalmos of 23 and 25 mm without limitation of eye movements, visual acuity of 0.7 with correction in both eyes (AO), fundus with mild diabetic retinopathy and thickening of the internal rectus muscles in the orbital CAT scan.
One month later he presented with retraction of both eyelids with limitation of upper and lateral motility in AO. Ocular tension (OT) was 26 mmHg in the right eye and 25 mmHg in the left eye. Treatment was started with topical beta-blocker and systemic corticosteroid treatment with 1 g/24 h of methyl-prednisolone iv 3 pulses.
Exophthalmos and TO were increasing, so topical carbonic anhydrase inhibitors were added, and the patient was referred for orbital radiotherapy with 2,000 Gy.
The course was unfavourable; proptosis increased to 27 and 30 mm and CT confirmed increased thickening of the internal rectus muscles. There was ophthalmoplegia in AO and corneal exposure in the left eye and bilateral orbital decompression was performed with fracture of the inferior, internal and external walls. Hormone monitoring revealed a severe hypothyroid crisis (TSH 44.5 IUI/mL (0.5-5.0), T3 42 ng/dL (60-180), Total T4 02.4 ng/dL (5.0-12.0), Free T4 0.3 ng/dL (0.7-1.8). The exophthalmos continued to worsen, so a lipectomy was performed on both orbits (1 cc of fat), showing infiltrated orbital muscles and tissues, enucleation of the left eye due to absolute glaucoma, and external and internal tarsorrhaphy in the right eye. Subsequently, thyroid hormones normalised (TSH 14.3, Total T4 5.9 and Free T4 1.1), proptosis decreased markedly and ocular motility increased, opening the tarsorrhaphy. OD examination showed VA of 0.1 as a consequence of severe optic neuropathy, TO of 18 mmHg, and mild-moderate diabetic retinopathy. The patient remains stable after 9 years of evolution.