An 18-year-old man who was being treated for Graves' disease presented to the clinic after several months of progressive eye changes. He had received a diagnosis of Graves' disease at 13 years of age and was treated with radioiodine. He had also been receiving thyroid hormone–replacement therapy for the past 4 years because of the subsequent development of hypothyroidism. Findings on physical examination revealed exotropia of the right eye, bilateral proptosis, periorbital edema, and conjunctival irritation (Panel A). Conservative management of his condition with oral prednisone provided no improvement. Subsequent bilateral orbital decompression surgery also failed to halt the progression of symptoms, including increasing loss of vision and extraocular motility disturbance. Computed tomography of the head showed worsening proptosis and enlarged eye muscles (Panel B, arrows). In children and adolescents, Graves' ophthalmopathy typically appears during the acute hyperthyroid phase and is usually mild and self-limited. In rare cases, severe Graves' ophthalmopathy persists or, as in this patient, is reactivated several years after its first occurrence, despite treatment and resolution of Graves' disease. In this patient, since symptoms progressed after conservative and surgical treatment, orbital radiation was administered and resulted in gradual clinical improvement.
NEJM Volume 362:e60 May 6,2010 Number 18
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