A case report of a patient with severe thyroid eye disease.

Objective: Our aim was to present a rare case of a middle-aged male patient, diagnosed with Graves' orbitopathy, which had an atypical rapid unilateral onset. Initially, the left eye presented exophthalmos, eyelid retraction, corneal ulceration, and pannus formation with an important vascular component due to corneal exposure. The same symptoms developed in the right eye within a short period of time. Methods: A 52-year-old man presented in our department with bilateral proptosis, decrease in visual acuity, and orbital pain, which developed initially in the left eye seven months before the right eye. Slit lamp examination revealed conjunctival hyperemia, purulent discharge, chemosis and inflammation of the caruncle in both eyes. The fluorescein eye stain test was positive due to corneal ulceration with the presence of cells and flare in anterior chamber in the RE (right eye). The LE (left eye) presented a corneal pannus. We documented the changes using a slit lamp biomicroscope, a fundus camera, orbital ultrasonography, and contrast CT (computer tomography) scans. Discussions: The severe Graves' ophthalmopathy represents a challenge both in active or inactive phase. Medical and surgical therapies should be taken into consideration in order to prevent the complications following corneal perforation or optic neuropathy. Also, ophthalmic, and systemic adverse reactions of systemic steroids used in the treatment of Graves' disease are important in the prognosis of the visual outcome. Conclusions: The management of Graves' ophthalmopathy is multidisciplinary and needs a very good therapy adherence in order to achieve a satisfactory prognosis and quality of life.

A systematic review of euthyroid Graves' disease (Review).

Euthyroid Graves' Disease (EGD) is a challenging pathology, due to its atypical clinical manifestations and the absence of abnormal thyroid function. Typically, thyroid ophthalmopathy is associated with elevated thyroid hormone levels and with the presence of thyrotropin receptor antibodies (TRAb) but a low percentage of patients remain euthyroid without developing hyperthyroidism during long-term follow-up periods. Although it is considered a different pathology, it shares a lot of similarities with Graves' disease, rendering the diagnosis more difficult. It is also important to note that ophthalmopathy may be the first clinical manifestation of Graves' disease and that thyroid function examinations do not present abnormalities over a long period. Treatment choices for euthyroid disease do not differ from those described in Graves' ophthalmopathy. However, it is considered that since euthyroid patients develop milder ophthalmic symptoms and their clinical activity score is lower, they tend to have better responses to treatment. Moreover, atypical sight-threatening cases such as exposure keratopathy and dysthyroid optic neuropathy with variable responses to therapy also exist. Disease management consists of a favorable collaboration between ophthalmologists and endocrinologists because patients with EGD can develop thyroid abnormalities over time. In conclusion, the diagnosis of EGD is difficult, clinical manifestations and evolution are variables depending on several factors, including the heterogeneity of TRAb. This review aimed to identify the characteristics of this disease by reviewing the clinical studies and case reports published in previous years.