Abstract 103: A difficult case of Graves' disease with ophthalmopathy

We report a case of 57-year old gentleman, a known case of hypertension and type 2 diabetes mellitus, who was diagnosed to have Graves' disease in 2020. He was diagnosed as a case of Graves' disease whenhe was evaluated for weight loss and generalized weakness, with elevated T3, T4, suppressed TSH and diffuse uptake on Tc 99m thyroid scan. He was started on Carbimazole and became euthyroid. About 5 months from the onset of thyrotoxicosis, he developed swelling over both the eyes (clinical activity score of 2/7). He was treated symptomatically with eye drops and head end elevation. However, his symptoms got worse after a few days and he developed eye pain (spontaneous as well as gaze evoked) associated with conjunctival redness (CAS 3/7). He was started on IV methyl prednisolone therapy [500 mg weekly for 6 weeks followed by 250 mg weekly for 6 weeks]. CT scan orbit and MRI orbits were suggestive of bulky rectus muscles with spared tendons. As relief was not evident, he was continued on oral prednisolone therapy. After some time, he was given a 2nd course of IV methyl prednisolone therapy (7 doses of 1 gm each). However, he had progressive loss in vision with CAS 7/7 in both eyes with compressive optic neuropathy. At this stage he was advised orbital radiotherapy and 20 Gy [2 GY *10 FRACTIONS] has been given by 3D CRT technique. He was simultaneously started on mycophenolate mofetil 500 mg bd. Oral prednisolone (10 mg per day) was continued. His vision partially improved after radiation therapy. CAS slowly improved. In this case of Graves' disease with ophthalmopathy and optic nerve compression, despite collective efforts of Endocrinologists and Ophthalmologists, outcome was not satisfactory.