A 45-year-old woman with known Graves' disease presents with proptosis, lid lag, and visual acuity of 6/60 bilaterally with dyschromatopsia and relative afferent pupillary defect. Hertel exophthalmometry shows 24 mm bilaterally. MRI orbit shows fusiform enlargement of inferior and medial recti with sparing of tendons. What is the most appropriate immediate management?

• A Orbital radiotherapy
• B Selenium supplementation and close monitoring
• C Intravenous methylprednisolone pulse therapy
• D Urgent surgical orbital decompression ✓

Explanation

This patient has dysthyroid optic neuropathy (DON) — the most sight-threatening complication of thyroid eye disease — evidenced by reduced VA, dyschromatopsia, and RAPD with significant proptosis. Urgent orbital decompression is required when IV steroids have failed or when optic nerve compression is severe and vision is acutely threatened. IV methylprednisolone is a first-line option for DON but surgery is required urgently if there is no response within 48–72 hours or if vision is severely compromised at presentation.

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.