This is a young female patient who came to our OPD with bulging eyes.

History of the patient with bulging eyes

bulging eyes

This young female patient was alright four years back when she noticed that she was losing weight despite having a normal appetite.

Overtime she felt more anxious and could not bear heat. She also noticed a change in her sleep pattern and had to go to the washroom for defecation more often.

The patient also noticed dry eyes, hair loss and difficulty climbing upstairs over timeShe consulted a doctor and was put on some medications after which some of her symptoms resolved but her weakness did not improve.

She noticed gaining more weight in the upper parts of the body and developed reddish linear lesions on her abdomen. Her menstrual cycles also became irregular.

Question:

What is the diagnosis?

What treatment was she started on by her doctor?

How should we plan her management?

bulging eyes
Follow up of our patient

The diagnosis in this patient is obvious. She was diagnosed as a case of Graves disease with Graves ophthalmopathy.

She was on carbimazole for the last many years. For graves ophthalmopathy, she was put on steroids after which she had worsening of proximal muscle weakness. The use of steroids also led to the weight gain and abdominal striae. Weight gain was more prominent in the chest and abdomen.

How should her management be planned?

Treatment of Graves disease include:

  1. Medical treatment for up to eighteen months or longer.
  2. Surgical treatment i.e. thyroidectomy.
  3. Radio-iodine therapy

Since our patient was on treatment for the last four years without spontaneous relapse of the disease, medical treatment was less of an option.

Our patient also had a non-palpable thyroid gland, thyroidectomy was also down the list.

Radio-iodine therapy could have been the best option provided she did not have graves eye disease. Radio-iodine therapy can exacerbate graves ophthalmopathy and may lead to vision loss.

The decision was difficult, however we planned to start the patient on high dose steroids one week prior to radio-iodine therapy and continue it for another six weeks after the treatment.

In case the eye symptoms worsen, orbital radiation and orbital surgery might be used.

A discussion on Graves disease will be posted soon.

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