This document presents the case of a 55-year-old male with a 3-year history of a neck swelling and 2-year history of bulging eyes. On examination, he has a multinodular goiter and signs of thyroid eye disease. Investigations show biochemical hyperthyroidism and imaging confirms a toxic nodular goiter with orbit involvement. He is diagnosed with toxic nodular goiter grade II and thyroid eye disease stage 2B, 3A, 4A, 5, and 6A based on the NOSPECS classification system. He is being treated with anti-thyroid medications and lubricating eye drops with plans for regular follow up.

1. PRESENTER: Dr. Anant Prakash Tripathi
SR: Dr. Ekta
CASE PRESENTATION

2. PATIENT PROFILE
 55 year Old
 male
 Resident of Delhi
 Govt employee
No financial interest and
consent was taken to
show the face

3. PRESENTING COMPLAINTS
 Swelling in front of the neck X 3 years
 Bulging of both the eyes (LE > RE) X 2 years

4. HOPI
Patient was apparently well two years back when he noticed
:
 Swelling in front part of his neck which was :
 Gradual, painless and progressive
 Initially it was size of a pea and has atttained a present size
Patient came to our hospital in july 2019 for the neck
swelling and was diagnosed to have thyroid disease

5. HOPI continues….
He is on treatment ( oral drugs) for the same for the past one
year
2 years back he noticed :
 Bulging of both of his eyes (LE > RE) which was :
 Insidious in onset
 Gradually progressive
 Associated with heaviness, gritty sensation and watering in
both eyes occasionally
 H/o weight loss, increased sweating present

6.  Not associated with pain in eyes
 No h/o diplopia
 No h/o increase in proptosis after coughing, sneezing,
crying or in bending forward
 No h/o postural variation
 No h/o any visible pulsations or change in colour of the
overlying skin
 No h/o fever, loss of appetite, arthralgia
 No h/o any other swelling in the body

7.  No h/o radiation therapy or chemotherapy in the past
 No h/o nasal block, recurrent sinusitis, frequent
respiratory tract infection, epistaxis
 No h/o ocular trauma or surgery
 No h/o headache,, projectile vomiting, seizures
 No h/o cough, haemoptysis, chest pain

8. PAST HISTORY
 He went to a physician and was prescribed certain
investigations and was diagnosed as a case of toxic
nodular goiter (USG, Tc99 scan, MRI brain n orbit) and
was started on medication.
 No h/o similar episodes in the past
 No h/o any surgery

9. PAST MEDICAL HISTORY
 k/c/o Hypertension on treatment for 5 years
 No h/o Diabetes mellitus, Tuberculosis or any other
systemic diseases

10. DRUG HISTORY
 Currently he is taking :
a. NM-20 ( Neo-Mercazole) 20 mg Twice a day
b. Tablet Ciplar 40 mg Thrice a day

11. FAMILY HISTORY
 No H/o similar ocular complaints in the family
 No H/o thyroid disease in any other family member

12. PERSONAL HISTORY
 Vegetarian by diet
 Normal sleep and appetite
 Normal bowel and bladder habits
 No H/o allergy/atopy
 Smoker (5-6 cigerettes/day) Stopped 3 months back

13. GPE
 average built , weight= 65 kgs
 Conscious, well oriented to Time, place, Person
 PR: 102/min, regular, high volume
 BP: 130/80 mmHg in the right arm in sitting position
 Afebrile
 RR: 16/min
 No pallor, icterus, cyanosis or lymphadenopathy ,
pretibial myxedema.

14. No hand tremors

15. SYSTEMIC EXAMINATION
 CVS: S1S2 normal, no murmurs
 RS: B/L air entry normal, no adventitious sounds
heard
 P/A : NAD with no organomegaly
 CNS: normal including cranial nerves

16. EXAMINATION OF NECK
THYROID SWELLING

17. EXAMINATION OF NECK
 INSPECTION :
 A swelling of approx.4 cm X 3 cm on the anterior aspect
of the neck extending on both the sides from the midline
with well defined borders and nodular surface
 It did’nt move with deglutition or protrusion of the
tongue.
 Skin over the swelling appeared normal
 PALPATION :
 A swelling of 4.5cm X 3 cm was palpated on the anterior
aspect of the neck extending on both the sides from the
midline with well defined borders and nodular surface,
firm in consistency

18. NECK EXAMINATION continues…..
 It didn’t move with deglutition
 There was no local rise of temperature or tenderness
 No cervical lymphadenopathy
 PERCUSSION :
Percussion over the manubrium gave a resonant note
 AUSCULTATION :
 No bruit heard over the thyroid gland

19. OPHTHALMIC
EXAMINATION

20. RE LE
VISUAL ACUITY (DISTANCE)
• UNAIDED
• WITH PH 6/9 p
6/6
6/12 p
6/6
NEAR VISION UNAIDED N 6 N 6
RETINOSCOPY (AT 2/3 rd
METERS WITH 0.8%
TROPICAMIDE AND 5%
PHENYLEPHRINE)
+ 1.0 D
+ 1.0 D
+ 0.50 D
+ 0.50 D

21. R/E L/E
ACCEPTANCE -0.50 DS 6/6 -1.0 DS 6/6
COLOR VISION Normal Normal

22. R/E L/E
HEAD POSTURE Erect
FACIAL SYMMETRY
Facial symmetry not maintained because of proptosis
EYEBROWS
EYELIDS
ADNAXAE
Wnl
Both eyelids retracted
Wnl
Wnl
Both eyelids retracted
Wnl
LACRIMAL APPARATUS
Puncta well apposed to
globe
And regurgitation test
negative
Puncta well apposed to
globe and regurgitation test
negative
22

23. PROPTOSIS WORK UP

24. EYE BALL RIGHT EYE LEFT EYE
SIZE
(exophthalmometry using
a scale)
21 mm (Exophthalmos +) 23 mm ( Exophthalmos +)
SHAPE Normal Normal
POSITION Orthophoric Orthophoric
ORBITAL MARGINS Intact , Insinuation of finger
was possible in all four
margins
Intact , Insinuation of finger
was possible in all four
margins
RETROPULSION TEST Resistance to retropulsion
test present
Resistance to retropulsion
test present
COMPRESSIBILITY &
REDUCIBILITY
Non compressible & Non
reducible
Non compressible & Non
reducible

25. R/E L/E
POSITION Orthophoric Orthophoric
PALPEBRAL
APERTURE(horizontal)
29 mm 29 mm
PALPEBRAL
APERTURE(vertical)
15 mm 16 mm
EXTRA-OCULAR
MOVEMENTS -1 0 -1
0 0
-1 0 -1
Mild Limitation of motion
in extreme gazes
-1 0 -1
0 0
-1 -1
0
Mild Limitation of motion
in extreme gazes

26. Extra-ocular Movements

27. R/E L/E
EYELID SIGNS
a. KOCHER’S SIGN
b. VIGOUROUX SIGN
c. ROSENBACH’S
SIGN
d. RIESMAN’S SIGN
Present
Present
present
Absent
Present
Present
present
Absent
THYROID EYE SIGNS
FACIAL SIGN ( JOFFROY’S SIGN) Present

28. UPPER EYELID SIGNS R/E L/E
VON GRAEFE’S SIGN Present Present
DALRYMPLE’S SIGN Present Present
STELLWAG’S SIGN Present Present
GROVE SIGN present present
BOSTON SIGN Absent Absent
JELLINK’S SIGN Absent Absent
GIFFORD’S SIGN present present
MEAN’S SIGN Present Present

29. R/E L/E
LOWER EYELID SIGNS
a. ENROTH’S SIGN
b. GRIFFITH’S SIGN
Present
Absent
Present
Absent
CONJUCTIVAL SIGN
( GOLDZEIHER’S SIGN )
present present
PUPILLARY
INVOLVEMENT SIGNS
a. KNIES’S SIGN
b. COWEN’S SIGN
Absent
Absent
Absent
Absent

30. THYROID EYE SIGNS
GOLDZIEGHER’S SIGN

31. Kocher’s sign

32. JOEFFROY’s SIGN

33. DALRYMPLE’s SIGN

34. ENROTH SIGNS & VIGOUROUX
SIGN

35. Mobius Sign ( video)

36. Rosenbach sign(video)

37. 37
CONJUNCTIVA RIGHT EYE LEFT EYE
BULBAR
Slight chemosis Slight chemosis
PALPEBRAL normal normal
FORNICEAL normal normal
SCLERA normal normal

38. CORNEA R/E L/E
SIZE 11 mm horizontal
10 mm vertical
11 mm horizontal
10 mm vertical
SHAPE/CURVATURE Normal in shape Normal in shape
SENSATION Present in all quadrants in both the eyes
TRANSPARENCY Maintained
BELLS PHENOMENA GOOD IN BOTH THE EYES

39. R/E L/E
ANTERIOR
CHAMBER
Normal in depth and
no abnormal contents
Normal and no abnormal
contents
IRIS Brown colour with
normal pattern
Brown colour with normal
pattern
PUPIL 2.5 mm size
Normal direct and
consensual light
reactions
2.5 mm size
Normal direct and consensual
light reactions
LENS clear clear
39

40. 40
RIGHT EYE LEFT EYE
IOP (GAT) in
primary gaze
IOP in upgaze
( GAT)
Schirmer’s I
Schirmer’s I
(with paracain)
13 mm of Hg
19 mm of Hg
28 mm
12 mm
13 mm of Hg
20 mm of Hg
24 mm
10 mm

41. FUNDUS R/E L/E
RED GLOW PRESENT PRESENT
MEDIA CLEAR CLEAR
OPTIC DISC
PINK IN COLOUR,
MARIGNS WELL
DEFINED
PINK IN
COLOUR,MARGINS
WELL DEFINED
CUP:DISC RATIO 0.3:1 0.3:1
A:V RATIO
2:3 2:3
FR PRESENT PRESENT
PERIPHERY WNL WNL

42. R/E FUNDUS PHOTOGRAPH

43. L/E FUNDUS PHOTOGRAPH

44. USG B scan (Orbit) for muscle
thickness
L/E R/E
 MR 5.46 mm
 LR 4.91mm
 SR 5.69 mm
 IR 6.27 mm
 MR 4.91 mm
 LR 4.81mm
 SR 4.78mm
 IR 5.83mm

45. USG B Scan ( L/E)
MR IR

46. USG B scan (L/E)
SR IR

47. USG B SCAN (R/E)
MR LR

48. USG B SCAN (R/E)
SR IR

49. Probable Diagnosis
Multinodular goiter Grade II with Thyroid associated
orbitopathy
( TAO) Type I, Stage 2B ,3A, 4A, 50 and 6A ( Based on
NOSPECS Classification for TAO) L/E > R/E

50. INVESTIGATIONS ( 20/5/17)
Hb-13g/dl
 PCV-48.4%
 RBC- 5.19 million
 MCV/MCH/MCHC- 93.2/29.8/31.9
 TLC- 97
 Blood sugar (Fasting)- 90 mg/dl

51.  LFT
 Total Bilirubin 0.9 mg /dl
 Direct Bilirubin 0.2 mg /dl
 Indirect Bilirubin 0.9 mg /dl
 SGOT 30 U/L
 SGPT 32 U/L
• KFT
 Urea 36 mg/dl
 Creatinine 0.9 mg/dl
 Urea Acid 3.8 mg/dl
• Urine rountine microscopy- normal

52. THYROID PROFILE
22/9/16 15/12/16 20/5/17
Free T 3 13.3 pg/ml 7.21 pg/ml 6.20 pg/ml
Free T 4 5.09 ng/dl 2.33 ng/dl 1.36 ng/dl
TSH < 0.015 ml IU/L < 0.015 ml IU/L < 0.015 ml IU/L

53.  USG Thyroid – Bilateral lobes and isthmus of thyroid gland
showed nodular enlargement left lobe – 18mm, nodule
(8.5x7.5mm) ; right lobe 20mm with increased vascularity.
 Tc 99 scan – suggests of toxic nodular goitre with cold
nodule in left lobe.
 MRI SCAN Brain & ORBIT- Report awaited

54. DEFINITIVE DIAGNOSIS
Toxic nodular goiter ( MNG) Grade II with Thyroid
associated orbitopathy ( TAO) Type I, stage 2B,3A, 4A,
5 0 and 6 a L/E > R/E

55. Treatment
 Lubricating e/d CMC 0.5 % both eyes
 Currently he is on anti-thyroid medication
 Reassurance of the patient
 Regular follow up

56. TAO Pathophysiology
Autoantibody against TSH receptor( TSH-R) in the Thyroid
Cross react with TSH-R in effector cells i.e. fibroblast ,
adipocytes and interstitial tissue between extra ocular
muscles
Inflammatory cellular infiltration ( T lymphocyte, plasma
cells, macrophages and mast cells) in orbital fat,lacrimal
gland and orbital interstitium
Lymphocytes infiltrate in the orbit predominantly of CD4+
and CD8+ T- cells with a few B-cells.

57. Interaction of CD4 T cells and fibroblast (orbital)
Release of cytokines such as IL-1b,TNF-gamma,TGF-b
Activate fibroblasts to secrete hyaluronic acid,
glycosaminoglycans.
Osmotic imbibition of water ,EOM swollen upto 8 times

58. Compressive optic Fibrosis of muscle Glycosaminoglycan
neuropathy
Restrictive myopathy orbital
fluid retention
increased
intraorbital volume
venous obstruction
Proptosis

59. NOSPECS CLASSIFICATION

60. EUGOGO CLASSIFICATION

61. CAS (MOURITZ ET AL)

62. THANK YOU