Ocular Hypertension, Glaucoma or Compressive Neuropathy in Patient with Active TED

Abstract

Introduction: Severe cases of thyroid eye disease with high intraocular pressure and visual field defects are a real diagnostic challenge requiring the exclusion of dysthyroid optic neuropathy and differential diagnosis with glaucoma. Aim: To report а case of a patient with active thyroid eye disease (TED), decreased visual acuity and elevated intraocular pressure. Materials and methods: We present a 52-year-old woman with TED in both eyes, class 2c3c4a6a (NOSPECS), with 6 points (by CAS) activity, who received corticosteroid therapy to a maximum cumulative dose of 5750 mg, with non-insulin-dependent diabetes mellitus and topical antihypertensive treatment with tapticom, brizadopt, and luxfen. The patient received full ophthalmological exam, tonometry, exophthalmometry, computer perimetry, optical coherence tomography (OCT) and computed tomography (CT) scan of orbits. Results: The following results were obtained: BCVA of right eye = 0.6, BCVA of left eye = 0.3; TOD = 26 mm Hg and ТОS = 21 mm Hg; exophthalmometry: 30 mm for the right eye and 31 mm for the left one; diplopia in all directions, edema and hyperemia of the eyelids and conjunctiva, eyelids retraction, sluggish pupil reactions, normal color vision, transparent ocular media, indistinct borders of the optic nerve disc, without glaucomatous excavation, tortuosity and dilation of the venules, retina - without diabetic changes, maculas - with normal reflex; CP datа for a localized inferotemporal visual field defect, CT data for thickening of all extraocular muscles, soft tissue orbital edema, and optic nerves compression. Conclusion: Our results confirmed the presence of dysthyroid optic neuropathy based on the decreased visual acuity, ophthalmo­scopic evaluation of the optic nerve head, lack of glaucomatous OCT changes, atypical perimetric changes and the CT data. The optic neuropathy is the most severe complication in patients with TED which develops due to the compression of the optic nerve and/or its blood supply from the enlarged extraocular muscles and soft tissues in the orbital apex and due to the mechanical tension of the optic nerve in cases moderate or severe proptosis is present.