Clinical Images  |   June 2020
Graves Orbitopathy
Author Notes
  • From the Edward Via College of Osteopathic Medicine–Carolinas Campus and the Regional Medical Center in Orangeburg, South Carolina. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Stefano Natali, OMS IV, 5770 SW 53rd Terrace, Miami, FL, 33155-6334. Email:
Article Information
Clinical Images   |   June 2020
Graves Orbitopathy
The Journal of the American Osteopathic Association, June 2020, Vol. 120, 425. doi:
The Journal of the American Osteopathic Association, June 2020, Vol. 120, 425. doi:
A 67-year-old woman presented to her gastroenterologist with 30 lb of unexplained weight loss, anxiety, and bilateral eyelid swelling with tenderness over a 5-month period. Her medical history included hypertension, stroke, and tobacco use. Esophagogastroduodenoscopy, colonoscopy, and abdominopelvic computed tomography (CT) results were unremarkable. CT of the orbit and sella turcica with and without contrast demonstrated bilateral exophthalmos with symmetric enlargement of the inferior and medial rectus muscles of both orbits (image A and image B), compatible with thyroid-associated orbitopathy. 
It is estimated that Graves orbitopathy (GO) is prevalent in only 20% to 25% of patients with Graves disease.1 Imaging demonstrates bilateral symmetric enlargement of the extraocular muscles (EOMs), most commonly affecting the inferior and medial rectus.2 A 2017 study3 was successful in quantifying the severity of active disease by using CT parameters to demonstrate increases in volumetric measurements of EOM and orbital fat in those with active inflammation vs healthy controls. For the most accurate measurements, the axial plane is preferred.4 The clinical activity score assesses GO severity by assigning a point for each pertinent clinical sign of inflammation. This score can be directly correlated to the EOM-to-total orbital ratio; when a patient's clinical signs improve, the ratio diminishes.5 
Tanda ML, Piantanida E, Liparulo L, et al. Prevalence and natural history of Graves' orbitopathy in a large series of patients with newly diagnosed graves' gyperthyroidism seen at a single center. J Clin EndocrinolMetab. 2013;98(4):1443-1449. doi: 10.1210/jc.2012-3873 [CrossRef]
Gonçalves AC, Gebrim EM, Monteiro ML. Imaging studies for diagnosing Graves' orbitopathy and dysthyroid optic neuropathy. Clinics (Sao Paulo. ). 2012;67(11):1327-1334. doi: 10.6061/clinics/2012(11)18 [CrossRef] [PubMed]
Byun JS, Moon NJ, Lee, JK. Quantitative analysis of orbital soft tissues on computed tomography to assess the activity of thyroid-associated orbitopathy. Graefe's Arch Clin Exp Ophthalmol. 2017;255(2):413-420. doi: 10.1007/s00417-016-3538-0 [CrossRef]
Bijlsma WR, Mourits MPl. Radiologic measurement of extraocular muscle volumes in patients with Graves' orbitopathy: a review and guideline. . Orbit. 2006;25(2):83-91. doi: 10.1080/01676830600675319 [CrossRef] [PubMed]
Le Moli R, Pluchino A, Muscia V, et al. Graves’ orbitopathy: extraocular muscle/total orbit area ratio is positively related to the clinical activity score. Eur J Ophthalmol. 2012;22(3):301-308. doi: 10.5301/ejo.5000018 [CrossRef] [PubMed]