title: Clinical challenge: An orbital Hickam's dictum.
abstract: A 53-year-old man with hyperthyroidism presented with asymmetric proptosis and diplopia. Thyroid-stimulating immunoglobulin was elevated, suggesting active thyroid eye disease. Imaging of the orbits revealed enlargement of the extraocular muscles, including irregular enlargement of the left lateral rectus muscle. Biopsy of the lateral rectus muscle demonstrated infiltration of the muscle with Bcl-2 positive B lymphocytes consistent with chronic lymphocytic leukemia (CLL). Evaluation for systemic lymphoproliferative disease was negative. The patient was treated with orbital radiotherapy at specific dosages for both TED and CLL. He responded well to therapy with a reduction in proptosis and diplopia and no evidence of recurrent CLL.
authors.affiliation: Wills Eye Hospital, Philadelphia, Pennsylvania, USA. Electronic address: michelle.wilson.md@gmail.com.
authors.forename: Michelle E
authors.initials: ME
authors.lastname: Wilson
authors.affiliation: Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
authors.forename: Sarah
authors.initials: S
authors.lastname: Thornton
authors.affiliation: Skull Base Division, Neuro-Ophthalmology Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA.
authors.forename: Ann P
authors.initials: AP
authors.lastname: Murchison
authors.affiliation: Skull Base Division, Neuro-Ophthalmology Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA.
authors.forename: Jurij R
authors.initials: JR
authors.lastname: Bilyk
mesh_terms: D004172:Diplopia / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology; D005094:Exophthalmos; D049970:Graves Ophthalmopathy / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D006801:Humans; D018828:Immunoglobulins, Thyroid-Stimulating / Q000627:therapeutic use*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009801:Oculomotor Muscles / Q000503:physiopathology*; D009915:Orbit / Q000000981:diagnostic imaging*
chemical_list: D018828:Immunoglobulins, Thyroid-Stimulating
keywords: Graves' ophthalmopathy; chronic lymphocytic leukemia (CLL); lymphoproliferative disorder; orbital inflammation; orbital lymphoma; proptosis; small lymphocytic lymphoma (SLL); thyroid eye disease