Management of a severe Graves’ orbitopathy

Purpose A case report of a 44‐year‐old woman with severe graves’ orbitopathy treated with high‐dose intravenous glucocorticoids, radiotherapy and bilateral orbital decompression by endoscopic surgery. Methods In the initial examination the corrected visual acuity was 0.2 in the right eye and 0.1 in the left eye, exophthalmos of 25 mm in both eyes, ophthalmoplegia mild to moderate ,lower keratitis, ocular hypertension (23 mm Hg in the right eye and 28 mm Hg in the left eye) despite treatment. She was treated with intravenous boluses of methylprednisolone 1g/day/3 days with clinical improvement although there was reactivation of her graves’ orbitopathy. She received orbital radiotherapy using a cobalt‐60 radiation source (total dose 20 Gy) after which, the patient experienced clinical improvement. Due to the large corneal involvement (exposure keratitis) of both eyes and the patient's clinical deterioration, it was decided to carry out orbital decompression by endoscopic surgery urgently. Results Ten months after surgery the patient has a corrected visual acuity of 0.7 in the right eye and 0.9 in the left eye. Proptosis, eyelid retraction and exposure keratopathy have disappeared, although walleye remain lower in both eyes. Conclusion The treatment of choice for moderate‐to‐severe and active Graves’ orbitopathy is high‐dose intravenous glucocorticoids. When there is no response, orbital radiotherapy is an appropriate treatment option. Orbital decompression is a very successful surgery to correct exophthalmos and improve edema taking place in the not active orbitopathy as rehabilitative or active in cases not responding to any medical therapy.