Bilateral Choroidal Folds in Thyroid-Associated Ophthalmopathy Without Compressive Optic Neuropathy: A Case Report

Abstract

Background This case presents a rare form of thyroid-associated ophthalmopathy with idiopathic choroidal folds, unlinked to optic neuropathy—an unusual finding in thyroid-related eye disease. Instead, bilateral nuclear cataracts and lens dislocation were identified as the primary causes of vision loss, emphasizing the importance of considering multiple, less common contributors in such cases. The decision to begin with cataract surgery exemplifies a tailored, effective approach to multifactorial vision loss, offering insights for cases with overlapping ocular issues. Given recent associations between COVID-19 vaccination and ocular symptoms like choroidal folds and scleritis, posterior scleritis was considered a possible explanation. This underscores the need for further investigation into atypical presentations of thyroid-associated eye disease. Case presentation: A 54-year-old male developed bilateral vision loss and choroidal folds one year following COVID-19 vaccination. Initially diagnosed with thyroid-associated ophthalmopathy, he underwent an adequate course of steroid pulse therapy with no visual improvement. Further assessment revealed bilateral cataracts and lens dislocation. Computed tomography identified mild extraocular muscle thickening but no orbital apex crowding, ruling out compressive optic neuropathy. Lens surgery subsequently restored his vision and normalized his visual fields. However, two months postoperatively, he experienced recurrent blurred vision and restricted movement in the right eye. Magnetic resonance imaging confirmed extraocular muscle enlargement, leading to a diagnosis of compressive optic neuropathy, and tocilizumab therapy was initiated. Following treatment, the patient demonstrated improved vision, reduced muscle thickness, and enhanced motility. Conclusions This case suggests that initial choroidal folds may be due to a combination of vaccine-related side effects and elevated orbital pressure, underscoring the potential for COVID-19 vaccination to cause atypical ocular symptoms.