Thyroid eye disease presenting with superior rectus/levator complex enlargement

Yao Wang, Pradeep Mettu, Talmage Broadbent, Phillip Radke, Kevin Firl, J. Banks Shepherd, Steven M. Couch, Angeline Nguyen, Amanda D. Henderson, Timothy McCulley, Collin M. McClelland, Ali Mokhtarzadeh, Michael S. Lee, James A. Garrity, Andrew R. Harrison

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12 Scopus citations


Purpose: To describe the demographic and clinical characteristics of patients with thyroid eye disease (TED) who present with predominate superior rectus/levator complex involvement. Methods: A multi-institutional retrospective review was performed to identify patients with TED who presented with superior isolated or predominate rectus/levator involvement. Baseline and subsequent visits were reviewed to characterize the clinical course. Results: Nineteen patients were identified. All patients had imaging demonstrating an enlarged levator/superior rectus complex. At presentation, the mean clinical activity score (CAS) was 2.1 (range: 0–5). Nineteen (100%) patients had proptosis on the affected side. Lid abnormalities, including upper/lower eyelid retraction and ptosis were higher on affected side compared to the unaffected side. Eleven (58%) patients had vertical misalignment. Mean thyroid stimulating immunoglobulin (TSI) was 3.7 (range: 1–7.1). Mean follow-up time was 18 months (range: 0–60 months). At last follow-up, the mean CAS was 1.3 (range 0–5). Ten (53%) patients had proptosis. Eleven (58%) patients had vertical misalignment. Repeat imaging in eight patients showed interval enlargement of other extraocular muscles. Conclusions: The presentation of TED with superior rectus/levator complex enlargement may be under-appreciated. Orbital imaging, as well as laboratory evaluation, may help support a diagnosis of TED. In the setting of abnormal TSI and/or thyrotropin receptor antibody, presence of upper eyelid retraction, and an otherwise unremarkable laboratory and systemic evaluation, a presumptive diagnosis of TED may be made, and the patient can be followed closely, as he/she is likely to develop involvement of other extraocular muscles, consistent with a more typical presentation of TED.

Original languageEnglish
Pages (from-to)5-12
Number of pages8
JournalOrbit (London)
Issue number1
StatePublished - Jan 2 2020


  • Extraocular muscle
  • Graves’ eye disease
  • superior recuts
  • thyroid eye disease


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