Detailed Treatment Process
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Medical Record July 25, 12:06 Department: Ophthalmology First visit Gender: Male Age: 51 years Chief complaint: Right eye proptosis for 1 month with decreased vision, hyperthyroidism for more than half a year History of present illness: No photophobia, tearing, or increased secretions. Physical examination: Right eye: Eyelid swelling (+), eyelid congestion (+), conjunctival congestion (+), conjunctival edema (+), lacrimal caruncle/fold congestion (-), retrobulbar resting pain (-), retrobulbar motion pain (-); CAS 4, cornea clear, anterior chamber clear, lens transparent/mildly opaque, pupillary light reflex (+) Left eye: Eyelid swelling (+), eyelid congestion (-), conjunctival congestion (+), conjunctival edema (+), lacrimal caruncle/fold congestion (-), retrobulbar resting pain (-), retrobulbar motion pain (-); CAS 3, cornea clear, anterior chamber clear, lens transparent/mildly opaque, pupillary light reflex (+) OD MRD1 4mm MRD2 5mm Lid closure gap 0mm Exophthalmometry 25mm (base 100 mm) Primary gaze Straight Extraocular movements Adduction (45) Abduction (45) Elevation (15) Depression (45) OS MRD1 4mm MRD2 5mm Lid closure gap 0mm Exophthalmometry 21mm (base 100 mm) Primary gaze Straight Extraocular movements Adduction (45) Abduction (45) Elevation (45) Depression (45) Diplopia: Denied Auxiliary investigations: June 20: FT₃ 7.81H, FT₄ normal, TSH <0.0083L, TRAb 8.95H, TSI 6.31H July 22: CD series and Ig series normal July 22: Cytokine panel (flow cytometry): Tumor necrosis factor-α 7.90 pg/ml; Interleukin-12P70 5.52 pg/ml. July 25: Orbital MRI with contrast: Extraocular muscles thickened bilaterally, more pronounced on the right, with T₂ hyperintensity and enhancement; soft tissues of right upper and lower eyelids showing T₂ hyperintensity Diagnosis: Thyroid dysfunction-related exophthalmos Management: The condition was explained to the patient. Due to current limitations in medical technology, there is no complete cure for thyroid eye disease. Available treatments—including medications, targeted monoclonal antibodies, radiotherapy, and surgery—cannot guarantee effectiveness for every patient. These approaches can only improve the condition and symptoms while minimizing the disease’s impact. After completing necessary tests to rule out contraindications, pulse steroid therapy was initiated with methylprednisolone 0.5 g + NS 500 ml IV drip, once daily for 3 days, along with gastric protection, calcium, and potassium supplementation. Strict smoking cessation was advised. Investigations ordered: (1) [Special examination] Scanning laser ophthalmoscopy (SLO); (2) [Special examination] Retinal thickness measurement (single eye); (3) [Special examination] Retinal thickness measurement (single eye); (4) [Special examination] Pattern electroretinogram (P-ERG) (single eye); (5) [Special examination] Pattern electroretinogram (P-ERG) (single eye); (6) [Special examination] Visual evoked potential (single eye); (7) [Special examination] Visual evoked potential (single eye); (8) [Special examination] Optical coherence tomography (OCT) (single eye); (9) [Special examination] Optical coherence tomography (OCT) (single eye); (10) [Special examination] Automated static perimetry.