Bilateral Exophthalmos and Depression: Not Always Endocrine Ophthalmopathy

SIR: Although there is a high prevalence of psychiatric disorders—and misdiagnosis—in patients with thyroid disease,¹ probably as a result of common biochemical abnormalities, our patient showing an extremely apparent bilateral exophthalmos had no thyroid dysfunction and apparently no immunological disease. Obviously, he presented with a treatment-refractory severe depressive episode without thyroid disorder, although one could have had the tentative diagnosis because of the ocular stigmata.

Case Report

A 71-year-old male, who was a former teacher, was admitted to our psychiatric hospital because of a severe major depressive episode with a duration of at least 2.5 years. His chief complaints were anhedonia, lethargy and depressed mood. His condition was initially therapy-resistant because a series of antidepressant (e.g., paroxetine, venlafaxine, citalopram, nefazodone, mirtazapine and finally tranylcypromine) with an irreversible MAO-inhibitor all failed to improve the depressive syndrome even at high dosages and despite long-term intake. He had suffered seven episodes, the first occurring 22 years earlier.

Physical examination revealed no abnormalities besides obesity and bilateral proptosis with conjunctival injection, lid lag and stare, all features of endocrine orbitopathy. The degree of the exophthalmos was so high, that the patient was asked by other patients if he had an acute disorder of the eyes. No painful ocular movements were reported. Blood pressure, electrocardiogram and chest radiograph results were normal. Thyroid-stimulating hormone (TSH), free T3 and free T4 levels were within normal limits also. Thyroid microsomal antibodies, TSH receptor antibodies and antinuclear antibodies all were negative. To exclude an endocrine orbitopathy associated with therapy-resistant depression such as euthyroid Graves' ophthalmopathy, an MRI of the head was performed. It showed bilateral exophthalmos (A, axial T2-weighted imaging of the orbitae; normal: 19–21 mm; here 22.9 and 23.3 mm) but failed to demonstrate any swelling or infiltration of the periocular muscles (B, coronar T1-weighted). This idiopathic exophthalmos obviously was due to an enlargement of the periorbital fat tissue. Because the patient experienced no discomfort due to his protruding eyes, he refused any surgical treatment.

After titration of lithium as an augmentation strategy showed only modest effect, a trial of electroconvulsive therapy was undertaken and was followed by complete recovery.