Thyroid Eye Disease With Significant Levator Involvement and Ptosis

Abstract

A case of an 87-year-old woman with a history of Graves disease presenting with a 5-year history of severe ptosis and very poor levator function of the left side is presented. MRI revealed marked enlargement of all extraocular muscles and significant enlargement of the left levator muscle. Given the patient's age and atypical presentation of thyroid eye disease (TED), she was taken to the operating room for biopsy and ptosis repair with frontalis suspension. Histopathological analysis revealed chronic inflammation and fibrosis consistent with Graves disease.

Eyelid Surgery in Thyroid Eye Disease

“…Blepharoptosis is rare in TED with few reports in the literature. 26,27 As per a recent demographic study from India, it was noted in 5.5% of cases. 28 In this series of 55 patients of TED with blepharoptosis, the most common etiology was found to be aponeurotic (38/55) followed by ocular myasthenia (13/55) and congenital ptosis (2/55).…”

More than meets the eye: a comprehensive review of blepharoptosis

“…Medical therapy can be utilized to treat certain forms of ptosis or it can be used to preoperatively maximize the chance of successful blepharoptosis repair. Thyroid eye disease can uncommonly present with ptosis and must be managed with corticosteroids and/or immunomodulatory therapy to ensure 6-9 months of stability before eyelid surgery can be considered [85,86] . Given the significant fluctuation of levator function in MG, cholinesterase inhibitors and/or corticosteroids should ideally be titrated to ensure stabilization for 3-4 years prior to surgical correction [43] .…”

Thyroid eye disease: a review

“…Common clinical signs are upper eyelid retraction, conjunctival and caruncle injection and/or oedema, eyelid oedema and/or erythema with diurnal variation, ocular motility disruption or strabismus and proptosis . Paradoxically, upper eyelid ptosis can also be a presenting sign of thyroid eye disease . The clinical evaluation for thyroid eye disease focuses upon determining clinical activity and severity by assessing visual acuity, pupils, colour vision, extraocular movements, visual field, exophthalmometry, external eyelid evaluation, slit‐lamp examination and dilated fundus examination.…”

“…13,14,17 Paradoxically, upper eyelid ptosis can also be a presenting sign of thyroid eye disease. 28 The clinical evaluation for thyroid eye disease focuses upon determining clinical activity and severity by assessing visual acuity, pupils, colour vision, extraocular movements, visual field, exophthalmometry, external eyelid evaluation, slit-lamp examination and dilated fundus examination. The correlating clinical sign for each of these examination components is outlined in Table 2.…”