Sir,

Spontaneous subluxation of the globe is a rare event. Luxation occurs when the equator of the globe is allowed to protrude anterior to the eyelid aperture. The orbicularis muscle then contracts, causing further anterior displacement and the globe is caught outside the eyelid aperture.1, 2

Case report

A 46-year-old Indian man complained of eyes spontaneously ‘popping out’ several times since 3 months.

Both eyes also luxated when the eyelids were spread manually (Figure 1). In the last 3 months, he had gained 12 kg and complained of fatigue. He had a history of gout, treated daily with indometacin. There was no family history of autoimmune disease. The patient smoked about 25 cigarettes per day. Ophthalmic examination showed a visual acuity of 25/25 in both eyes and an intraocular pressure of 22 mmHg right and 23 mmHg left. His upper eyelids were swollen and extremely lax. There was a mild lash droop bilaterally. There was no lid lag nor eyelid retraction. Hertel measurements were 25 mm in both eyes at a base of 90 mm.

Figure 1
figure 1

Left. A 46-year-old. Indian male who developed rapid weight gain and the floppy eyelid syndrome secondary to Hashimoto's disease. Right. Subluxation of his left eye.

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A slight exophoria was noted. The ductions were normal in all directions. Slitlamp examination revealed a chronic papillary conjunctivitis. The cornea showed diffuse punctuate keratitis. The anterior chamber was quiet. The fundoscopic examination was normal. Computerized tomography (CT) imaging showed bilateral proptosis, an enlarged orbital fat volume, a normal aspect of the extraocular muscles and a normal, deep bony orbit. (Figure 2)

Figure 2
figure 2

Left. Axial orbital computerized tomography (CT) scan showing bilateral proptosis due to an increased orbital fat volume. Right. Coronal CT scan also shows an (old) fracture of the right orbital floor.

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Laboratory tests revealed a high TSH, a low FT4, a normal T3 and high TPO antibodies, so an autoimmune hypothyrodism (Hashimoto's disease) was diagnosed and treated with levothyroxin. They also revealed a normal value of cortisol, a Cushing's syndrome could be excluded.

Comment

We assume that the combination of exophthalmia and FES caused repetitive spontaneous globe subluxations. The increased orbital fat volume may be explained by the massive and quick weight gain. The association between the FES and globe luxation proves very rare, since it was recently reported in only two case reports.2, 3 In the published cases, there was no history of Hashimoto's disease. As the classical FES occurs in obese, middle-aged men, it is surprising that spontaneous globe luxation is not encountered more frequently.

While bilateral proptosis due to an increase of orbital fat without extraocular muscle enlargement may be features of thyroid-associated orbitopathy (TAO), there was no orbital inflammation or other characteristic signs and symptoms suggestive of this disorder.