We present the case of a 60-year-old smoker diagnosed with hypothyroidism after thyroid ablation with radioactive iodine and severe OG with bilateral optic neuropathy, classified according to the Clinical Activity Criteria (CAS) with a score of 5 out of 7: pseudophakia in both eyes, inferior punctata OD, palpebral oedema, conjunctival hyperemia and chemosis and caruncle hyperemia and oedema. Visual acuity (VA) was also measured, despite not being included in the CAS criteria for evaluating the capacity of the visual system, obtaining a VA of 0.4 in the right eye (R.O.) and VA of 0.5 in the left eye (L.O.). Normal VA is equal to 1. He started with ocular symptoms 1 year before diagnosis.
The aim of treatment was to restore euthyroidism, smoking cessation and disease control by intermittent high-dose intravenous corticosteroids (6 doses of methylprednisolone 500 mg/week, followed by 6 doses of methylprednisolone 250 mg/week). Despite this, little response was obtained and bilateral orbital decompression was necessary due to worsening VA.
However, the orbitopathy continued to progress to a VA of finger count in OD and VA less than 0.05 in OI, necessitating a second orbital decompression.
Having exhausted all therapeutic possibilities, authorisation for the use of Tocilizumab "off-label" in this patient was requested from the Pharmacy and Therapeutics Committee of our hospital. After obtaining authorisation and informed consent, treatment was started with intravenous Tocilizumab at a dose of 8 mg/kg body weight, once every 4 weeks, for a total of 5 doses.
After 2 weeks from the start of treatment, the patient began to show an improvement in the signs and symptoms of the pathology, both subjective and objective, with the VA in the OI at this time being equal to 0.05. At 9 weeks the improvement continued, showing a VA in the LAA equal to 0.1, with almost no signs of oedema and conjunctival and palpebral erythema. At 18 weeks the VA in the LA was equal to 0.6 and after 20 weeks of treatment the VA in the LA reached a value of 1 (normal VA). In the OD, the improvement could not be quantified at that time due to the strabismus present after the decompressions performed, and surgical intervention was pending to resolve this pathology.
After 5 sessions with Tocilizumab, the patient has no inflammatory activity and a VA of 0.1 in the OD and VA of 1 in the OI with no adverse effects, with a CAS score of 0 out of 7.