Emergencies in Neuro-Ophthalmology: A Case Based Approach

Dr. Lee. Thyroid eye disease is typically not a difficult clinical diagnosis. The most common cause of unilateral or bilateral proptosis in adults is thyroid eye disease. I generally make the diagnosis clinically based on lid retraction, lid lag, proptosis, and ophthalmoplegia. Ultrasonography or orbital noncontrast CT scan are useful for confirmation of the clinical findings but are not mandatory if there is no doubt about the diagnosis and there is no evidence for thyroid optic neuropathy. I recommend an assessment of both activity and severity of disease. Active disease might benefit from immunosuppression versus inactive disease which might benefit from reconstructive or rehabilitative surgical intervention. Severity drives the decision making for treatment. In my opinion, mild disease is best treated conservatively as the natural history is typically one of improvement, spontaneously, over time. Compressive optic neuropathy (CON), however, generally requires treatment and it is reasonable to consider a short course of intravenous or oral steroids as a trial. Many patients have contraindications to steroids or may not be able to tolerate side effects and so my threshold for surgical treatment is low. Orbital decompression may be necessary for vision threatening compressive optic neuropathy. I recommend an orbital imaging study (generally noncontrast CT scan) prior to orbital decompression and for patients who seem to have markedly asymmetric or strictly unilateral findings. Control of the systemic thyroid status and discontinuation of smoking are important first line treatments for all degrees of thyroid eye disease.

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Acute Proptosis with Red Eyes

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