Purpose

A 76-year-old male with Graves’ disease, Hashimoto thyroiditis, and a remote smoking history presented with binocular diplopia while euthyroid on methimazole. Exam revealed normal afferent function in both eyes (OU), restricted extraocular movements OU, and 4mm of relative proptosis on the left by Hertel exophthalmometry. Computed tomography (CT) imaging showed homogenous, asymmetric enlargement of the left medial rectus and inferior recti (IR) muscles, sparing the myotendinous junction, consistent with thyroid eye disease (TED) (Figure 1A). Disease activity improved without intervention.

Six years later while clinically quiescent, CT demonstrated regression of prior muscle enlargement with heterogeneous low-attenuation intramuscular infiltrate (Figure 1B). Subsequently, the patient developed reactivated disease with compressive optic neuropathy on the right. CT imaging revealed interval enlargement of the right extraocular muscles with orbital apex crowding and stability on the left (Figure 1C). Treatment with corticosteroids and orbital decompression led to improvement. Eighteen months later, the patient had relapsing disease on the left with reactivation of previously chronic-appearing extraocular muscles, specifically the left IR (Figure 1D).

The radiographic appearance of extraocular muscles in TED changes from homogenous enlargement while active to heterogeneous regression in chronic disease, reflecting fibrosis and fat infiltration. This case illustrates a less common phenomenon: extraocular muscles may revert to an active radiologic phenotype after undergoing chronic remodeling. This suggests a radiographic “burnt out” appearance does not preclude future inflammatory reactivation. Extraocular muscle remodeling in TED may be more dynamic than traditionally appreciated.

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Methods

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Results

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Conclusion

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Additional Authors

First name	Last name	Base Hospital / Institution
Grace	Baldwin	Massachusetts Eye And Ear Infirmary
Lisa	Lin	Wilmer Eye Institute
Suzanne	Freitag	Massachusetts Eye And Ear Infirmary

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