Occult Thyroid Eye Disease in Patients Presenting with Dry Eye Symptoms

Purpose: To describe the clinical presentation, laboratory features, and treatment outcomes in a series of patients with occult thyroid eye disease (TED). Design: Retrospective observational case series. Methods: Among 539 patients who were referred for dry eye evaluation over 2 years, 21 were diagnosed with occult TED, based on typical findings in orbital echography. Medical records of these patients were reviewed to collect information on demographics, clinical findings, laboratory studies, and treatment response. Results: All patients presented with symptoms of dry eye. Median age of patients was 57 years (range, 24 to 78 years), with the majority female (86%). No patients carried prior diagnosis of TED or had typical findings of TED such as proptosis, dysmotility, or diplopia. Suspicion of TED was based on conjunctival hyperemia with or without chemosis localized to extraocular muscles (100%), and subtle widening of interpalpebral fissure (48%). Clinical findings included corneal fluorescein staining (57%), rapid tear break-up time (31%), and abnormal Schirmer test (19%). Nineteen percent of patients had other rheumatologic disorders commonly associated with dry eye: Sjögren syndrome (n = 3), and rheumatoid arthritis (n = 1). Patients were treated topically using cyclosporine 0.05% 2 to 4 times a day, with or without steroid. Other treatments were also employed as necessary including warm compresses, artificial tears, and puntal plugs. Majority of patients (76%) had improvement of their symptoms. Conclusion: Occult TED is a potential cause of inflammatory ocular surface disease with dry eye symptomatology and should be considered in the differential diagnosis when evaluating dry eye patients.