Thyroid eye disease

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(aka Grave's Ophthalmoplegia, Hyperthyroidsim Related Infiltrative Ophthalmoplegia, Thyroid Associated Orbitopathy)

Enlargement of the extraocular muscles caused by T-lymphocyte infiltration, adipose hypertrophy, scarring and irreversible proptosis.

Order of Extraocular Muscle Involvement (I'M SLO)

  • Inferior rectus
  • Medial rectus
  • Superior rectus
  • Lateral rectus - if isolated lateral rectus think orbital pseudotumor
  • Obliques

  • Bilateral and symetric involvement is typical
  • Tendon is typically spared (unlike orbital pseudotumor)
  • Can be exacerbated by radioiodine therapy (prednisone can prevent flare)
  • Eye complications occur in 25-50% of Grave's
  • Painless


  • Lymphoma
  • Orbital pseudotumor - idiopathic painful inflammation, "dirty fat"
  • Sarcoidosis
  • Tolosa Hunt syndrome - painful opthalmoplegia caused by cavernous sinus inflammation (likely continuum of orbital pseudotumor)