CASE PRESENTATION

SUDIR GHIMIRE
Patient particulars:

• Patient number: 1046878

• Mrs. Bandana Tamang
• 32 years/female
• Jorpati, kathmandu
• housewife
• 2079/01/03
Verbal consent taken for photographs
Chief complain
Protrusion of both eyeball since 2 years
History of present illness
• Patient presented with complain of Protrusion of both eyeball since 2
years, which was gradual in onset, progressive in nature. It was
associated with mild pain during ocular movement, discomfort,
lacrimation.
• She also gives history of swelling over anterior neck since 2 years
• History of loss of weight with good appetite and heat intolerance
• No h/o diplopia, blurring of vision, photophobia, FB sensation,
discharge
• No h/o hyperpigmentation of lids
• No h/o fever, headache, nausea, vomiting
• No h/o postural variation
• No h/o diurnal variation
• No h/o dysphagia, dysphonia, easy fatigability, drooping of eyelids
• No h/o radiation or chemotherapy in past
• No h/o trauma
History of past illness
• History of hyperthyroidism since 7 month and under regular
medication
• No history of significant ocular disease in the past
• No history of HTN, DM, PTB
Family history
• No significant similar illness in any other family members
Drug history and allergic history
• Tab carbimazole 5 mg p/o TDS
• Tab Propanolol 10 mg p/o TDS
• No any significant allergic history
Personal history
• Non vegetarian in diet
• Non smoker
• Non alcoholic
General physical Examination
• Patient is averagely built and nourished
• Cooperative, well oriented to time, place and person
• Weight ~ 55kg
• NO pallor, icterus, cyanosis, lymphadenopathy, edema, dehydration.
• Fine tremors present
Vitals
• Pulse: 90 beats per min, regular in rhythm, volume
• BP: 120/80 mm of Hg
• RR: 18/ min
• Temp: afebrile
Systemic examination
Respiratory system:
B/L normal vesicular breath sound
CVS: S1 and S2+ M0
GI system:
Abdomen- soft, non-tender, no organomegaly
CNS:
HMF , speech intact
Sensory/motor system intact
Skin: no rashes
Ocular examination
RE LE
• Visual acuity:
6/6 6/6

• HCRT: central
• Cover test: orthophoria
• Convergence: 10 cm
 Right eye Left eye

Axial proptosis Axial proptosis

Lids Edema present Edema present

Conjunctiva No congestion, No chemosis No congestion, No chemosis

Cornea Clear Clear

Anterior chamber VHG IV, quiet VHG IV, quiet

Iris Normal color and pattern Normal color and pattern

Pupil RRR, no RAPD RRR, no RAPD

Lens clear clear
 Fundus
Both Eyes: • A:V-2:3
• Media –clear • FR- present
• Optic disc- well defined
margin, round, pinkish
• CDR-0.2:1:0.2
• NRR: intact
Extraocular Muscle:

Full and free in all gazes

No ocular pain during movement
Evaluation of Proptosis
• Head posture is normal
• Facial symmetry is present
 Inspection
• Axial proptosis is noted
• Eyebrows were normal with no
evidence of madarosis.
• periorbital edema present
• Kochers sign present
• Lid signs:
- Stellwag’s sign present
- Von Graefe’s sign absent
- Enroth’s sign present
- Dalrymple sign present
- Gifford’s sign present
• Lagophthalmos: absent
• No variation of proptosis was observed in the right eye with posture
especially on bending forwards
• Proptosis was nonpulsatile
Palpation
• Orbital margins were intact
• Proptosis was noncompressible and nonreducible
• No thrills or pulsations felt
• No evidence of warmth or tenderness over both Eyes
Auscultation
• No bruits were heard in both eyes
Eyelid measurements
• VPF: RE 10 mm, LE 10 mm
• HPF: RE 28 mm, LE 28 mm
• Superior scleral show: 1 mm
• Hertel’s exophthalmometry:
At 110mm : RE 22mm, LE 22 mm
•IOP measurement:
RE 14 mmhg, LE-12 mmhg
No change in upgaze or downgaze position
•Color vision: normal
•Schirmer’s test: RE-10mm LE-14 mm
Investigation
TFT
• T3: 9.19 pg/ml (2.77-5.27)
• T4: 2.73 ng/dl (0.78-2.19)
• TSH: <0.015 µI/Uml (0.465-4.68)
USG thyroid:
• Diffusely enlarged
• Heterogeneous hyperechoic gland with
increased vascularity
• Suggestive of graves disease
Provisional diagnosis
• Thyroid Eye Disease class 2
Differential diagnosis
• Cavernous sinus thrombosis
• Idiopathic orbitalinflammatory disease (pseudotumor)
• Orbital cellulitis
• Metastasis
Management
• Gtt. Refresh tear 1 drop BE QID for 1 month
• Continue antithyroid drug as per ENT department
THANK YOU