A 35-year-old woman with Graves' disease presents with bilateral proptosis of 23 mm (Hertel exophthalmometry), restricted upgaze, and compressive optic neuropathy on the left evidenced by an RAPD, desaturated color vision, and early visual field loss. CT orbit shows apical crowding. The MOST urgent intervention is:

• A High-dose systemic corticosteroids IV (pulse methylprednisolone)
• B Orbital decompression surgery ✓
• C External beam radiotherapy to the orbits
• D Selenium supplementation

Explanation

Compressive optic neuropathy (DON) in thyroid eye disease with apical crowding requires urgent orbital decompression surgery to relieve pressure on the optic nerve and prevent permanent visual loss. IV methylprednisolone pulse therapy can be used as initial bridge therapy but surgery is required urgently when DON is present with apical crowding that does not respond to steroids within days. Radiotherapy has a delayed effect (weeks-months) and is not suitable for acute DON. Selenium is for mild active TED to prevent progression, not for DON.

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.