A 33-year-old female patient was referred to me from an area optometrist for evaluation of ptosis OS. My usual protocol is to evaluate the ptosis, assure there isn’t a neurological or other underlying condition causing the ptosis, take the necessary measurements required by my surgeon partner, and then schedule the appropriate eyelid surgical procedure to correct ptosis. 

Evaluation of this patient, however, illustrated a different problem. Upon examination, it was obvious we weren’t dealing with ptosis at all, instead, this was pseudoptosis. The left eyelid actually falls between the upper edge of the pupil and the upper limbus which is normal. The right eyelid, however, falls near the upper limbus which is the abnormal eyelid in this case. This patient actually has proptosis OD.

The most common cause of proptosis in someone this age is Grave’s disease although other causes of unilateral proptosis, such as an orbital tumor or mucocele, is possible. To determine the diagnosis, I ordered a CT of the orbits without contrast with 3mm axial and coronal sections and TSH with reflex free T4 thyroid blood levels. The CT was positive for proptosis OD without retrobulbar abnormality or mass and the TSH was very low at 0.01 (normal levels 0.4-4.5) and the T4 level was elevated at 1.6 (normal 0.8-1.8). The patient was referred to an endocrinologist and was started on pharmaceutical treatment for hyperthyroidism.

Controlling hypothyroid levels is actually easier to achieve pharmaceutically than controlling hyperthyroid levels, therefore many patients will end up having surgical or radiologic treatments to cease thyroid production and then be switched to thyroid replacement (usually levothyroxine). Regardless, control of thyroid blood levels often will not control the thyroid eye disease and oculoplastic surgical intervention could be necessary for the future. This patient will be monitored by me for further ocular manifestations of Grave’s disease (intermittent diplopia, VF changes, increasing proptosis) but will hopefully have spontaneous resolution of her proptosis with appropriate treatment of her hyperthyroidism.