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Poorly controlled intraocular pressure in a female patient with exophthalmos and systemic disease on steroid treatment: a differential diagnosis puzzle and a treatment dilemma

Poster Details

First Author: E.Zopounidou GREECE

Co Author(s):    E. Kanonidou   I. Zampros   N. Lakidis   G. Sakkias     

Abstract Details

Purpose:

Exophthalmos occuring bilaterally is associated with Graves ophthalmopathy, a disease entity characterised by hyperthyroidism and infiltrative ophthalmopathy. The infiltrated muscles cause globe compression with secondary IOP elevation as well as compressive optic neuropathy. Corticosteroids are a class of drugs that may produce IOP elevation by an open-angle mechanism. Our purpose is to present an interesting case of uncontrollable elevated intraocular pressure in a patient with coexisting exophthalmos and systemic autoimmune disease under steroid treatment.

Setting:

Department of Ophthalmology, ‘’Hippokrateion’’General Hospital of Thessaloniki, Thessaloniki, Greece

Methods:

A 67 year old female presented at the outpatient department of our hospital with exophthalmos and elevated intraocular pressure in both eyes (RE: 49mmHg, LE: 27mmHg). The patient had been diagnosed with hyperthyroidism 30 years earlier and underwent thyroidectomy and consequent LT4 substitute therapy. Furthermore, she was diagnosed with bullous pemfigoid and received systemic steroid treatment with methylprednisolone.

Results:

The results of the ophthalmological examination were as follows: visual acuity 4/10 in RE and 6/10 in LE, intraocular pressure 49mmHg in RE and 27 in LE, cup/disc ratio 0, 6-0, 7, diplopia on the upper gaze. Visual fields showed arcuate defect in RE and concentric defect in LE. TSH, FT4 and PTH values were normal and endocrinology assessment concluded in inactive thyroid ophthalmopathy. MRI findings did not indicate thyroid ophthalmopathy. Topical treatment: dorzolamide/timolol drops twice/day, brimonidine tartrate three times/ day and latanoprost once daily. No significant decrease in the intraocular pressure. Patient referral to surgical intervention and valve insertion.

Conclusions:

Ocular hypertension caused by thyroid ophthalmopathy is common when orbital muscles are affected and aqueous outflow is inhibited. Drug-induced glaucoma is often associated with steroid treatment and deregulates intraocular pressure values. In addition primary open angle glaucoma should not be easily excluded from the diagnostic algorithm. Approach of such patients with exophthalmos and systemic disease that requires steroid treatment poses diagnostic puzzles and subsequent severe treatment dilemmas.

Financial Disclosure:

NONE

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