Clinical presentation: A 65-year-old woman was referred for evaluation of thyroid problems. She has been treated for hyperthyroidism for more than a year. Thyrostatic therapy was stopped four months ago. She had severe eye symptoms including diplopia despite large dose steroid therapy and external irradiation.

Palpation: no abnormality.

Laboratory tests: euthyroidism (TSH 3.01 mIU/L, FT4 14.6 pM/L, TSAb 5.2 U/L (normal value < 1.5).

Ultrasonography. The thyroid was moderately hypoechogenic and presented a discrete echonormal area in the central part of the right lobe.

A total thyroidectomy was advised. Histopathology disclosed diffuse goiter corresponding to Graves' disease. There were no nodules on histopathology.

Follow-up results. The patient became euthyroid on daily 125 microgram levothyroxine. Although the constant conjunctivitis has stopped, the diplopia remained the same. An eye-muscle surgery was performed nine months after thyroidectomy which resulted in almost complete restoration of life quality regarding the vision. (Diplopia remained only in upward gaze.)

Comments.

1. The echonormal lesion in the central part of the right lobe had irregular borders and shapes, two properties suggesting that the area was not a nodule in pathological sense.

2. The only way of restoration of life quality in severe thyroid associated ophthalmopathy (TAO) is definitive therapy followed by eye-muscle surgery. Without the former procedure, the hyperthyroidism might recur which could destroy the success of the eye-surgery. We prefer total thyroidectomy over radioiodine therapy because the latter might have adverse effect on TAO.

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