The floppy thyroid eye disease

To report unique clinical features and management challenges in patients with co-existing Thyroid Eye Disease (TED) and Floppy Eyelid Syndrome (FES).

Retrospective, multicentric, interventional case series of 9 patients presenting as TED with FES over a period of eight years.

Seventeen eyes with co-existing TED and FES were analysed. The average age at presentation was 51.5 years. There were five males and four females in the cohort. Hypothyroidism and hyperthyroidism were noted in four cases each, while a single patient was euthyroid at presentation. The average exophthalmometry value was 25.5 mm (range, 22-30 mm). All but one had bilateral presentation. Of the 17 eyes, 13 (76%) had episodes of spontaneous globe luxation. Eleven eyes (65%) had congestive signs or surface exposure, which mimicked clinically active TED. Lash ptosis was observed in six (35%) eyes. All (100%) eyes had significant lower eyelid retraction (LER) with inferior scleral show. Upper eyelid retraction was absent in 14 (82%) eyes. Of the six cases where orbital imaging was available, fat-predominant disease was seen in nine orbits.

TED and FES can rarely co-exist. The lax or ptotic upper eyelid tends to mask upper eyelid retraction, with LER being a more obvious sign. Spontaneous globe luxation may be more common in this cohort, warranting early orbital decompression. Congestive signs and corneal exposure may mimic clinically active TED, potentially leading to corticosteroid misuse.