Category: Thyroid

Monitor: 17

17 - UNILATERAL GRAVES' OPHTHALMOPATHY IN PRIMARY HYPOTHYROIDISM: A CASE REPORT

Thursday, Apr 25
1:30 PM – 2:00 PM

Objective : A 40-year-old diabetic (on oral hypoglycaemic agents), normotensive lady, known case of primary hypothyroidism (on Levothyroxine 100 mcg daily for 1 year), attended to the Endocrine Outpatient Department of BIRDEM with the complaints of bulging of left eye along with redness, pain, discomfort and progressive visual worsening for 2 weeks. 


Methods : On examination she was clinically euthyroid with no thyromegaly and normal vitals. She was urgently referred to eye clinic for ocular examination. Ophthalmological examination revealed axial proptosis of left eye with lid lag, conjunctival chemosis, ophthalmoplegia and diplopia. Biochemical investigations confirmed the euthyroid status(S. FT4:15.0 pmol/l, S. TSH: 2.56 µIU/ml) with positive Anti-thyroid Antibodies (S. Anti-TG: 71.7 IU/ml, S. Anti-TPO: >1300.0 IU/ml). Blood sugar profile was uncontrolled (FBS 8.0 mmol/l, 2HRS ABF 11.2 mmol/l, HbA1c 7.5%). Patient was advised for orbital imaging by ophthalmologist to identify the cause. 


Results : CT scan of orbit revealed swollen bellies of left extra-ocular muscles with mild proptosis of left eyeball, suggesting Graves’ Ophthalmopathy.  Systemic steroid was started at a dose of 60mg daily with gradual tapering of the dose for next 6 weeks. She was switched to insulin therapy for better diabetes control and to combat the risk of steroid induced worsening of hyperglycemia. She was followed up after one month with improved eye condition. 


Discussion :

Thyroid eye disease or Graves’ Ophthalmopathy is a potentially vision threatening auto-immune disease which is mostly associated with hyperthyroid (70%), less frequently euthyroid (20%) and hypothyroid (5%) status. Unilateral ocular finding is not a common manifestation and must be distinguished from other causes of unilateral eye disease such as orbital tumor or cellulitis.


Conclusion : Maintenance of strict euthyroid state in Graves’ Ophthalmopathy is mandatory as because both hyper- and hypo-thyroidism can worsen the situation. These cases demand multidisciplinary approaches from both endocrine and ophthalmology sub-specialties. 

Noor E Nazneen

Senior Medical Officer
Endocrine Department, BIRDEM General Hospital, Dhaka, Bangladesh, Bangladesh

I am a Diabetic and Endocrine Specialist working at BIRDEM General Hospital, Dhaka, Bangladesh

Mohammed Mahboob Iftekhar

Senior Medical Officer
Endocrine Department, BIRDEM General Hospital, Dhaka, Bangladesh

I am a Diabetic and Endocrine Specialist working at BIRDEM General Hospital, Dhaka, Bangladesh

A.M.B Safdar

Associate Professor
Cardiology Department, BIRDEM General Hospital, Dhaka, Bangladesh

I am Cardiac Specialist at BIRDEM General Hospital, Dhaka, Bangladesh