Department of Endocrinology and Metabolism, National Hospital Organization Sendai Medical Center.
Olympia Eye Hospital.
Tohoku J Exp Med. 2020 Dec;252(4):321-327. doi: 10.1620/tjem.252.321.
Dysthyroid optic neuropathy is a severe manifestation of Graves' ophthalmopathy that can result in permanent vision loss. We report a 37-year-old pregnant woman with Graves' ophthalmopathy which was deteriorated to dysthyroid optic neuropathy in the third trimester of pregnancy. Diplopia, bilateral eye lid retraction, lid edema and proptosis were observed in the 29th week of gestation. Thyroid-stimulating hormone (TSH) level was decreased with a normal level of free triiodothyronine (FT3) and an upper normal level of free thyroxine (FT4). Anti-TSH receptor antibodies (16.2 IU/L, reference range < 2.0 IU/L) and thyroid stimulating antibody (4,443%, reference range < 120%) were positive. Magnetic resonance imaging (MRI) demonstrated a significant enlargement of the extraocular muscles with a high signal intensity on T2-weighted image. She was diagnosed as Graves' ophthalmopathy and subclinical hyperthyroidism, and followed without treatment. In the 34th week of gestation, the symptom of color vision abnormality appeared, suggesting dysthyroid optic neuropathy. She delivered a female infant during the 36th week of gestation. Four days after delivery, she had a spontaneous orbital pain. MRI showed that the extraocular muscles were more enlarged than the findings in the 29th week of gestation. FT3 and FT4 levels were mildly elevated. Dysthyroid optic neuropathy was diagnosed. She was treated with methylprednisolone pulse therapy and retrobulbar injections of betamethasone valerate, and the ocular symptoms improved. The present case shows that the glucocorticoid therapy performed one week after delivery is effective against Graves' ophthalmopathy which was deteriorated to dysthyroid optic neuropathy during the third trimester of pregnancy.
甲状腺相关性眼病性视神经病变是 Graves 眼病的严重表现，可导致永久性视力丧失。我们报告了一例妊娠 37 周的 Graves 眼病患者，在妊娠晚期发展为甲状腺相关性眼病性视神经病变。患者在妊娠 29 周时出现复视、双侧眼睑退缩、眼睑水肿和眼球突出。促甲状腺激素（TSH）水平降低，游离三碘甲状腺原氨酸（FT3）水平正常，游离甲状腺素（FT4）处于正常上限。抗 TSH 受体抗体（16.2IU/L，参考范围 <2.0IU/L）和甲状腺刺激抗体（4443%，参考范围 <120%）阳性。磁共振成像（MRI）显示眼外肌明显肿大，T2 加权图像上呈高信号。她被诊断为 Graves 眼病和亚临床甲状腺功能亢进症，未接受治疗。在妊娠 34 周时，出现色觉异常症状，提示甲状腺相关性眼病性视神经病变。她在妊娠 36 周时分娩了一名女性婴儿。产后第 4 天，她出现自发性眶痛。MRI 显示眼外肌比妊娠 29 周时更肿大。FT3 和 FT4 水平轻度升高。诊断为甲状腺相关性眼病性视神经病变。她接受了甲基强的松龙脉冲治疗和倍他米松戊酸酯球后注射，眼部症状改善。本例表明，产后一周开始的糖皮质激素治疗对妊娠晚期发展为甲状腺相关性眼病性视神经病变的 Graves 眼病有效。
