title: [Treatment of difficult endocrine orbitopathy cases].
abstract: BACKGROUND
  There can be many differences between the clinical presentation and disease development of endocrine orbitopathy. Uncommon clinical expressions of the disease may lead to misinterpretations causing difficulties in treatment. Misdiagnosed forms of the disease can end with irreversible vision loss.
  
  
  METHODS
  A 79-year old female with severe bilateral thyroid eye disease, progressive almost blinding visual loss, with the absence of exophthalmos is described. Second, a 39 year old female with a unilateral thyroid eye disease and relapsing episodes of the disease is reported.
  
  
  CONCLUSIONS
  Exophthalmos, as a symptom, occurs in about 60 % of the patients diagnosed with thyroid eye disease. The absence of exophthalmos may be due to a reduced volume (atrophy ) of retrobulbar fat tissue. Progressive visual loss can be related to direct compression of the optic nerve by thickened eye muscles in the orbital apex. Thyroid eye disease presents itself unilaterally in 5-11 % of all cases and involvement of the contra lateral orbit may occur years later. A relapse of the disease may be triggered by episodes of hypo- or hyperthyroidism. Smoking is a significant risk factor for orbitopathy relapse.
  
  
  CONCLUSIONS
  Physicians treating thyroid eye disease should be aware of atypical clinical presentations in order for early satisfactory treatment. An interdisciplinary approach including ophthalmologists, endocrinologists and oto-rhino-laryngologists is necessary for optimal management.
authors.affiliation: HNO-Klinik, Hals- und Gesichtschirurgie Kantonsspital St. Gallen. Thomas.Breuer@kssg.ch
authors.forename: T
authors.initials: T
authors.lastname: Breuer
authors.forename: D
authors.initials: D
authors.lastname: Ammann-Rauch
authors.forename: A J
authors.initials: AJ
authors.lastname: Tasman
mesh_terms: D000328:Adult; D000368:Aged; D001766:Blindness / Q000209:etiology; D019299:Decompression, Surgical; D005094:Exophthalmos / Q000175:diagnosis / Q000601:surgery / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D006111:Graves Disease / Q000175:diagnosis; D049970:Graves Ophthalmopathy / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy*; D006801:Humans; D009915:Orbit / Q000601:surgery*; D012008:Recurrence; D012307:Risk Factors; D012907:Smoking / Q000009:adverse effects; D016540:Smoking Cessation; D013965:Thyroidectomy; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014785:Vision, Ocular