Active thyroid eye disease with pretibial myxedema

  

A patient with a 10-year history of hyperthyroidism treated with levothyroxine and liothyronine developed one month of intermittent double vision, redness, and foreign body sensation. His exam was notable for vision 20/20 in the right eye and 20/30 in the left eye with an intraocular pressure of 23 and 19 in the right and left eye, respectively. External exam was notable for lid retraction in both eyes and proptosis as well as limitations in several gaze directions. Slit lamp revealed inferior punctate epithelial erosions, and the posterior segment was within normal limits. Notably, the patient also presented with non-pitting edema of the lower extremities with thickened, indurated skin. The patient received a diagnosis of active thyroid eye disease and pretibial myxedema and was initiated on teprotumumab. He improved during treatment but symptoms regressed after completion of the first course. The patient then underwent a second course with improvement, but symptoms regressed again. The patient also received oral glucocorticoids as well as methotrexate without much improvement. The decision was made to undergo a third cycle of teptrotumumab and the patient again responded with improvement in both ocular symptoms and amelioration of the lower extremity manifestations.

Presentation Date: 09/19/2024

Issue Date: 10/18/2024