title: Occult thyroid eye disease in patients with unexplained ocular misalignment identified by standardized orbital echography.
abstract: OBJECTIVE
  To describe the clinical presentation, orbital echography (OE) findings, and neuroimaging results of patients with chronic unexplained ocular misalignment, which includes patients with clinically occult thyroid eye disease (TED) that is identifiable through a characteristic OE appearance.
  
  
  METHODS
  Retrospective observational case series.
  
  
  METHODS
  Seventy-eight patients with chronic ocular misalignment suspected of TED because of a history of systemic thyroid disease, proptosis, dysmotility, positive forced ductions, or eyelid retraction or lag were categorized as TED positive, negative, and indeterminate with the use of standardized OE. Demographic, clinical, OE, computed tomography, and magnetic resonance imaging information was collected. Analyses determined the prevalence of TED and differences between TED positive, negative, and indeterminate groups.
  
  
  RESULTS
  Fifty-five percent of the findings were suspicious for and most consistent with TED (TED positive); 26% of the findings were TED negative, and 19% of the findings were TED indeterminate. Of 30 patients with newly diagnosed TED by OE, 70% had no lid retraction, and 20% had no other findings of TED. The inferior rectus followed by the superior rectus/levator complex, medial rectus, and lateral rectus muscles were the most frequently involved muscles. Neuroimaging that was performed in only 26 of 78 patients (33%) did not appear to yield additional diagnostic information.
  
  
  CONCLUSIONS
  TED is a potential cause of chronic unexplained ocular misalignment in a substantial proportion of patients. These patients frequently present in an occult fashion without other clinical findings that are typical of TED. In these patients, a diagnosis of TED by OE can reduce further costly evaluation. OE appears to have significant clinical usefulness in the diagnosis of TED in patients with unexplained ocular misalignment.
authors.affiliation: Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA. nickvolp@mail.med.upenn.edu
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Volpe
authors.forename: James A
authors.initials: JA
authors.lastname: Sbarbaro
authors.forename: Kym
authors.initials: K
authors.lastname: Gendron Livingston
authors.forename: Steven L
authors.initials: SL
authors.lastname: Galetta
authors.forename: Grant T
authors.initials: GT
authors.lastname: Liu
authors.forename: Laura J
authors.initials: LJ
authors.lastname: Balcer
mesh_terms: D002908:Chronic Disease; D005141:Eyelid Diseases / Q000000981:diagnostic imaging / Q000209:etiology; D005260:Female; D049970:Graves Ophthalmopathy / Q000150:complications / Q000000981:diagnostic imaging*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009801:Oculomotor Muscles / Q000000981:diagnostic imaging*; D009915:Orbit / Q000000981:diagnostic imaging*; D012189:Retrospective Studies; D013285:Strabismus / Q000000981:diagnostic imaging* / Q000209:etiology; D014057:Tomography, X-Ray Computed; D014463:Ultrasonography