Severe Reactivation of Thyroid Eye Disease after Laser Iridotomy

Case Report

Annals Thyroid Res. 2016; 2(2): 63-65.

Severe Reactivation of Thyroid Eye Disease after Laser Iridotomy

Estrella Fernández¹*, Silvana Schellini2,3, Sahar M Elkhamary4 and Alicia Galindo-Ferreiro2,5

¹Hospital Clínic de Barcelona, Institut Clinic d’Oftalmologia, Spain

²Oculoplastics and Orbit Division, King Khaled Eye Specialist Hospital, Saudí Arabia

³Department of Ophthalmology Faculdade de Medicina de Botucatu - UNESP, Brasil

4Diagnostic Imagina Department, King Chalad Eye Specialist Hospital, Saudí Arabia

5Department of Ophthalmology, Compel Asistencial Palencia, Spain

*Corresponding author: Fernández E, Hospital Clínic de Barcelona, InstitutClínic d’Oftalmologia, Barcelona, Spain

Received: August 08, 2016; Accepted: September 10, 2016; Published: September 21, 2016


Background: We present a very rare case of severe reactivation of Thyroid Eye Disease (TED) following bilateral Neodymium-doped Yttrium Aluminium Garnet (Nd:YAG) laser iridotomies.

Case Report: A63-year-old female with previous episode of mild active TED and in stable eu thyroid condition underwent bilateral YAG iridotomies. After three weeks, she developed a severe reactivation of TED, with Dysthyroid Optic Neuropathy (DON). She was treated with intravenous methylprednisolone for 3 consecutive days, twice, with no improvement. Subsequently she underwent three-wall orbital decompression, radiotherapy and steroids with good outcome.

Conclusion: Laser iridotomy may lead to reactivation of TED in predisposed individuals.

Keywords: Laser Iridotomy; Thyroid eye disease; Reactivation; Dysthyroid optic neuropathy


Thyroid Eye Disease (TED) is a self-limited disease that commonly affects females in their fifth decade of life [1]. In most cases the onset of glandular and orbital disease occurs within 18 months of each other, although cases have been reported that precede or appear after 20 years [2,3].

Various factors contribute to the onset/ severity of disease or the reactivation of TED such as cigarette smoking [4,5], following trauma [6] and retro bulbar anesthesia for cataract surgery [7-10], periocular surgery [10,11], Botulinum Toxin (BTX) injections [12], orbital decompression [11] or radio iodine [13].

To our knowledge, there are no published reports of Dysthyroid Optic Neuropathy (DON), due to TED reactivation associated with laser iridotomies. We report a case of severe reactivation of Graves ophthalmopathy after laser iridotomies.

Case Report

A 63-year-old Caucasian female with uncontrolled hyperthyroidism presented to the oculoplastic clinic complaining of foreign body sensation and redness in both eyes. The patient denied diplopia or pain. On examination the eye were mildly red, with swollen upper eyelids and mild chemosis. Hertel exophthalmometry indicated an Intercanthal distance (IC) of 115mm, 21 mmfor the right eye (OD), and 21 mm for the left eye (OS). The patient had full extra ocular motility, Margin-Reflex Distance (MRD1) was 4mmOD, 4mmOS, and inferior scleral show was1mm OD, and 1mm OS. The remaining examination was normal. An endocrinologist had prescribed oral Tiamazol7.5 mg/day (Tirodril, ALDO-UNION, Barcelona, Spain). The patient was assessed according to the European Group on Graves Orbitopathy Guidelines for the Management of Graves Orbitopathy (EUGOGO) Clinical Activity Score (CAS). The final diagnosis was mild active TED (CAS=3/7).

The patient was advised to use artificial tears, ointments, dark glasses and control of risk factors for progression such as smoking and had the Thyroid dysfunction treated. Six months later, the patient bécame euthyroid (TSH 4.1 and T3 3.22) using Tirodril and TED was inactive.

One year later, the euthyroid state was maintained and she presented with conjunctival injection, chemosis and no secretion. Slit lamp examination revealed grade II anterior chamber (Schaffer grading). The patient was diagnosed as anangle-closure suspect and underwentbilateral prophylactic peripheral irodotomies with neodymium-doped yttrium aluminium garnet (Nd:YAG) laser treatment at 11o’clockOD and at 1 o’clock OS. After YAG laser, the patient was prescribed Neomycin, bacitracin and dexamethasone (Maxitrol, Alcon Inc., Fort Worth, Tx, USA) qidover 10 days then tapered to stop. Apraclonidine 0.5% eyedrops were prescribed just for the day of the laser application.

Over the following 3 weeks after the iridotomies, the patient experienced a severe worsening of her ocular symptoms. On examination, visual acuity (VA) using a Snellen chart was 0.6OD and0.2OS.The color vision (Ishihara pseudo-isochromatic plates) was impaired with scores of 16/21 ODand 1/21 OS, the extraocular motility was limited in all positions of gaze except adduction, eyelid edema was present along with conjunctival hyperemia and chemosis (CAS 6/7). Exophthalmometry IC of 115 mm was24 mm OD and24 mm OS, intraocular pressure (IOP) in primary position was 24 mmHg in both eyes and increased to 32 mmHg OD and 35 mmHg OS in up gaze. Fundus examination indicated edema of both papilla with peril-papillary hemorrhages and exudates (Figures 1A,B). Magnetic Resonance Imaging (MRI) indícate enlargement of the extraocular muscles sparing the tendinous insertion (Figures 1C-F). T2-weighted images allowed assessment of muscle-water content, and hence a high signal was seen in active disease with crowded apex due to the enlargement of markedly enhanced extraocular muscles. Visual field (Humphrey analyzer; Carl Zeiss Meditec AG, Jena, Germany) indicated severe general loss of visual field OD and an inferior altitudinal defect OS (Figure D-E).

Citation: Fernández E, Schellini S, Elkhamary SM and Galindo-Ferreiro A. Severe Reactivation of Thyroid Eye Disease after Laser Iridotomy. Annals Thyroid Res. 2016; 2(2): 63-65.