209stimulating hormone level of 21.7 mu/l (normal 0.5-5.0), but serum thyroxine was normal. Other routine bloods including full blood count, urea and electrolytes, serum glucose and liver function tests were also normal. Thyroid autoantibodies and TSH receptor assays were not performed. This subclinical hypothyroidism 1 supported our diagnosis of dysthyroid ocular myopathy. Treatment with oral thyroxine was commenced with a subsequent reduction in this patient's serum cholesterol. He remains visually asymptomatic with normal visual fields, unchanged disc appearances, and normal intraocular pressures in the primary gaze position. CommentThe English, medieval, Franciscan, philosopher William of Occam, proposed the principle of Pluralitas non est ponenda sine necessitate meaning that plurality should not be posited without necessity. Physicians understand this to mean that a patient's diverse symptoms and signs be explained by a single pathophysiology.Our asymptomatic patient's abnormal lipids and IOP were discovered by separate, ad hoc 'screening' procedures. Initially they were considered separate matters; ultimately a common causation became clearillustrating Occam's razor.Both elevated lipids 1 and intra-ocular pressure 2 are recognised features of hypothyroidism in Graves disease. Elevated intra-ocular pressure is due to the inelastic inferior rectus muscle compressing the globe as it fails to relax against the upward pull of its antagonist. 3 Failure to recognise underlying hypothyroidism was of practical importance for this patient, who suffered the adverse effects from oral lipid lowering agents, lipid levels only becoming controlled on treatment with Thyroxine. In addition topical Timolol treatment was been shown to cause lipid derangement in healthy volunteers. 4 We feel that hypothyroidism should be considered in patients who present with elevated lipids 1 and elevated IOP-especially when optic discs or visual fields are normal.Subclinical hypothyroidism may present with a spectrum of clinical ophthalmic signs, but the presence of raised IOP particularly on up gaze, lid lag on down gaze, and the presence of deranged thyroid profiles are sufficient evidence of dysthyroid ocular myopathy in our case. In our opinion the presence of raised intraocular pressure in these patients contraindicates the use of ocular hypotensives in the presence of normal disc appearances and visual fields.
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