Thyroid eye disease is a heterogeneous autoimmune orbital reaction typically manifesting in middle age. The inflammation may parallel or remain isolated from a related inflammatory cascade in the thyroid called Graves' disease. The orbital manifestations can lead to severe proptosis, dry eyes, strabismus, and optic neuropathy. In this article, we will discuss this unique condition including the ophthalmic findings and management.

If giant cell arteritis is suspected as a cause of visual loss, emergent management is necessary. Clinical suspicion should prompt the practitioner to obtain laboratory studies and initiate treatment prior to establishing the diagnosis. The evaluation includes immediate erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complete blood count (CBC). Treatment begins with high-dose intravenous corticosteroids. We recommend intravenous methylprednisolone (250 mg every 6 h) for 3 to 5 days. During that time, a temporal artery biopsy should be performed for pathologic diagnosis. We also begin daily adjunctive aspirin orally. After the initial bolus of intravenous corticosteroids, therapy transitions to oral prednisone administered at 1 mg/kg per day until the activity of the disease process attenuates, as demonstrated by improvement in systemic symptoms and normalization of both ESR and CRP. This change usually occurs in the first 3 to 4 weeks. The patient should be followed closely, with therapy tapered as guided by systemic symptoms, ESR, and CRP. To maximize the use of remaining vision, appropriate patients should be referred to specialists for help with low-vision therapies, assistive devices, and precautions to protect the better-seeing eye.

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An old and currently seldom used technique, true preplaced sutures, is described in a case that was high risk for choroidal hemorrhage (CH). A penetrating keratoplasty technique, termed graft-over-host technique, was used allowing the surgeon to expeditiously close the eye in the event of CH. After partial-thickness trephination, true preplaced sutures through the corneal host tissue were passed. After complete trephination, the corneal donor graft was placed under the host and sutured in a controlled fashion. The preplaced sutures had been drawn immediately, giving a broad secure cover, allowing controlled permanent suturing of the graft while selectively removing the preplaced sutures. When CH occurs, the preplaced sutures allow the surgeon to quickly close the eye securely.