Title: Grave’s Disease...Pseudotumor Cerebri...Don’t Settle for What is in Front of You—Look Behind the Eyes! Authors: Muen Yang OD, Joan K Portello OD MPH MS FAAO Abstract: Grave’s disease and chronic papilledema may have similar signs as orbital cavernous

Grave’s disease and chronic papilledema may have similar signs as orbital cavernous hemangioma. This report discusses the diagnosis and management of a patient who has all three conditions with the first two masking the latter. I. Case History  Patient demographics: 48 year old Caucasian female.  Chief complaint: Pt presented for routine eye exam without particular complaints. Upon questioning, patient reported rare diplopia in primary gaze but it “resolved instantly” when she focused.  Ocular, medical history: Patient was suspect for Grave’s Ophthalmopathy related to thyroid cancer which was removed in 2004. Patient had chronic asymptomatic papilledema secondary to pseudotumor cerebri (PTC) diagnosed 15 years ago. Patient had hypertension that is well-controlled with medications.  Medications: Synthroid, Losartan, Metoprolol, Amlodipine.  Other pertinent information: Swelling of the left upper and lower lids, which the patient thought might be related to a robotic hysterectomy in 2011. II. Pertinent findings At initial exam 2 years ago:  Clinical: o BCVA: OD 20/20, OS 20/20 o EOM/pupils: mild restriction of elevation and abduction OS. PERRL (–)RAPD OU. o Stereoscopy/color test: both within normal limits. o Tonometry: OD 19mmHg, OS 24mmHg with Goldmann applanation tonometry.  Physical: o External: lid retraction (Dalrymple’s sign) with symmetrical mild proptosis OU. o Pt is obese. o Biomicroscopy: Left superior and inferior lids are swollen. Open angles OU. Other elements of the anterior segment are unremarkable. o Dilated fundus exam: C/D ratio 0.25 OU. Elevated rim tissue with indistinct borders (-)hemes OD/OS. Macula, periphery, vasculatures, vitreous are unremarkable. o Humphrey VF: 81 point screening: OD 74/81, OS 74/81, scattered non-specific peripheral loss OU. A follow-up VF SITA Standard 24-2 testing: OD inferior nasal step/arcuate defect, OS nasal defect. Patient was instructed to return to clinic for IOP check, but patient was lost to follow up. At subsequent exam 1 year ago:  Clinical: o BCVA/pupils: same as previous findings, WNL. o EOM: 4+ restriction of up/lateral gaze OS. o Tonometry: increased asymmetry OD 18mmHg, OS 26mmHg with Goldmann.  Physical: o Biomicroscopy/Dilated fundus exam/External: same as previous findings. o Humphrey VF SITA Standard 24-2: OD-increase in an inferior nasal step/arcuate defect, OS increase in an nasal defect. Patient was referred to OMD, then was seen by multiple neuro-ophthalmologists. The report is as follow:  Proptosis OD 23mm < OS 26mm. Retropulsion OD normal, OS resistant. CT scans of the orbits and MRI of the brain showed a well circumscribed mass in the left intraconal space: it wrapped around the optic nerve, collapsed the optic sheath, and had a mass effect on the medial rectus muscle. OMDs were uncertain whether the mass was longstanding or recent. A biopsy was indicated.  Dilated fundus exam confirmed bilateral disc edema. OCT showed thickened RNFL OU. MRI/CT showed a partially empty sella and distended optic nerve sheath OU, findings that are consistent with papilledema. Cerebrospinal fluid yielded 44cmH2O.  EOM showed limitation in elevation, depression, and abduction of OS; with bilateral lids retraction, these findings confirmed Grave’s ophthalmopathy although EOM restriction can also be attributed to the orbital mass OS. Patient returned for optometric exam this year:  BCVA: OD 20/20, OS reduced to 20/40+