I've encountered many patients with well manifest thyroid eye disease ( TED ) who were not aware of their illness - like this man - where the scleral show and his left exophthalmic eye could be noticed easily faraway .

I've also observed many TED patients in whom exophthalmos developed after the onset of the motility defect . Others did not develop exophthalmos at all and represented only by motility disorders.

 In TED, limitation of elevation is the most common ocular motility disorder ;this, followed by limitation of horizontal gaze . Bilateral myopathy of the medial recti may lead to the characteristic convergence insufficiency which is a prominent feature in this patient, leading to sever discomfort at near work .

Work up of this patient :

1. Thyroid function tests .

2. Ophthalmoscopy , OCT optic nerve , Perimetery (Compression of the orbital apex by the enlarged extraocular muscles, especially the medial rectus , may cause congestion of the optic nerve and decrease in visual acuity ) .

3. MRI orbit ( looking for the characteristic MR muscle enlargement with sparing of the tendon - Coca cola bottle appearence ) .

Management suggested :

Of course , first to be managed is the hormonal disorder , if optic nerve congestion is suspected steroid therapy could be applied .   

Therapy for convergence insufficiency is the work of orthoptics. Indeed its treatment is the most successful application of orthoptics and in most cases provides long-lasting symptomatic relief .  The ophthalmologist must remember that in TED convergence insufficiency is a reversible disorder and that the decision to perform surgery should be made with extreme cautious and not until all other therapeutic possibilities, including prisms base-in, have been tried. If surgery is imperative, I advocate BMR resection .