A 55-year-old male develops complaints of sudden onset persistent diplopia while looking ahead since a week. On questioning, he lets us know that he has had similar complaints of diplopia intermittently, especially on waking up for the last two months which did not interfere with his daily activities. He has also noticed complaints of redness in the right eye and a feeling of grittiness in both eyes. His wife adds that it seems like his eyes are ‘popping out’ of his sockets. He has noticed weight loss of around 8% over the last few months with insomnia and fatigue, both of which he attributed to his current change of his boss at work and hence was not investigated for. His sister has primary hypothyroidism and is on levothyroxine supplements. He is a smoker (20 pack years). On examination, he is well built, with a BMI of 26 kg/m2. He appeared anxious, has a pulse rate of 100 bpm, blood pressure of 150/90 mm Hg, warm moist palms, has fine tremors of extremities and a diffuse goiter with no bruit. Eye examination reveals proptosis both eyes (R > L). Lateral movement of the right eye is restricted to 30° from midposition. Clinical activity score was right eye 4/7 (conjunctival redness, pain on movement, chemosis and swelling of the eyelids and the left eye 3/7 (pain on movement,conjunctival redness and chemosis). No dermopathy or nail changes noticed.
Investigations revealed a normal hemogram with normal total and differential leukocyte count. TSH <0.001 μIU/mL, free T4 80 ng/dL. Technetium uptake scan shows diffuse increased uptake over the entire gland. A diagnosis of Graves’ disease with moderate-to-severe, clinically active ophthalmopathy is made.
What is the position of radioiodine therapy in patients with ophthalmopathy?
Medicine
The risk of exacerbation of pre-existing GO following radioiodine therapy is negligible, especially in patients with inactive ophthalmopathy, as long as postradioiodine hypothyroidism is avoided. A definite proportion of patients, especially patients with active disease experience the progression of pre-existing GO within 6 months after radioiodine therapy.
This risk is almost eliminated by giving a short course (4–12 weeks) of oral glucocorticoids after radioiodine therapy, and avoiding post-treatment hypothyroidism. Our patient is given a course of oral steroids for 4–6 weeks for his ophthalmopathy and he is also started on methimazole in divided doses. He is strictly instructed to stop smoking. He is instructed about eye care and lubrica-tion. At review, his diplopia has improved and the clinical activity score is down to 1/7 both eyes. The dose of methimazole is reduced and the dose of steroid tapered down gradually over 3 weeks.
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