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Answers: 2004 series -  December 7, 2004 Lecture 4 of 50  NEXT»

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This 49-year-old woman presents with a complaint of progressive blurring vision right eye more than left eye, with transient visual obscurations, occasional orbital pain, and horizontal binocular diplopia. Medical history is positive for hyperthyroidism.  She is status post radioactive iodine treatment. She also has insulin dependent diabetes mellitus, hypertension, irregular heart beat, and sinusitis. 

1.  What is the most likley diagnosis:   

c -- A patient with significant history for thyroid disease with associated ocular symptoms such as diplopia, visual field defects, progressive blurring vision, and occasional orbital pain would all be consistent with a diagnosis of thyroid orbitopathy. The one striking feature in this case is the CT scan . One can observe the enlarged muscle bellies without enlargement of the tendons which is a typical finding for Graves' disease. Although the other conditions listed may cause blurred vision, thyroid orbitopathy, confirmed by the CT images, is the most likely answer. In the case of orbital pseudotumor, although the muscles are enlarged on the CT scan, the tendons are typically not spared.

2.  What is the most likely reason for the visual field changes:  

b -- The coronal cuts of the CT scan clearly show the crowded apex of the orbit secondary to the enlarged muscle bellies. This is causing compression on the optic nerve which in turn causes blurred vision.

3.  What is the next best step for this patient: 
  d -- The most effective way to relieve pressure on the optic nerve, especially in the right eye, is to perform orbital decompression. Decompression of two walls would be the preferred surgery. Medial wall decompression is the most effective, combined with either a lateral wall or floor decompressions.

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