End stage thyroid ophthalmopathy presenting with bilateral exposure keratitis

The present case reports a 70-year-old female patient who presented with bilateral exophthalmos, lagophthalmus, and exposure keratitis. An aggressive topical treatment was commenced that included fortified vancomycin and ceftazidime. She was subsequently diagnosed with severe thyroid ophthalmopathy (TO) due to severe static and dynamic tremor that raised suspicion and abnormal thyroid function tests indicating Graves’ Disease. She was diagnosed with bilateral exposure keratitis secondary to TO in which the clinical activity score was assessed as 5. As her TO was sight-threatening, she was administered intravenous pulse methylprednisolone, followed by bilateral balanced 2-wall (medial and lateral) decompression and lateral temporary tarsorrhaphy surgeries. As her exophthalmos and lagophthalmos improved postoperatively, both eyes’ keratitis significantly regressed, and left scar tissue in the cornea. This extreme case should raise awareness for clinicians in the eti-ological investigation of exposure keratopathy to identify sight-threatening thyroid ophthalmopathy and promptly initiate appropriate treatment.