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By Wilmar M. Wiersinga, George J. Kahaly

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Visual field assessment will detect defects in most patients with other evidence of DON. These are commonly central paracentral and/or inferior [3]. It should be appreciated that these tests can show normal fluctuation and may be very misleading in patients with marked visual loss [64] or confounding pathology such as cataract, age-related maculopathy or glaucoma. Unfortunately, the age of patients at greatest risk of DON makes them more likely to show these confounding pathologies, and indeed a recent study showed confounding pathology in 28% [24].

Ballottement of the globe is a crude test, but these patients will have tense rather than soft orbits. In the alternative scenario, there is such extreme proptosis from self-decompression of the orbit that there is no compression of the optic nerve, but rather it is stretched, as are the muscles. In some of these patients there is global restriction of motility. Although in one series this scenario accounted for 24% of DON [61], others have found it to be much less common [23, 24]. The typical presentation of DON is of a symptomatic patient with ocular surface discomfort or aching and evidence of muscle restriction.

Bartley GB, Fatourechi V, Kadrmas EF, Jacobsen SJ, Ilstrup DM, Garrity JA, Gorman CA: Clinical features of Graves’ ophthalmopathy in an incidence cohort. Am J Ophthalmol 1996;121: 284–290. Dickinson AJ, Perros P: Controversies in the clinical evaluation of active thyroid-associated orbitopathy: use of a detailed protocol with comparative photographs for objective assessment. Clin Endocrinol 2001;55:283–303. Mourits MP, Koornneef L, Wiersinga WM, Prummel MF, Berghout A, van der Gaag R: Clinical criteria for the assessment of disease activity in Graves’ ophthalmopathy: a novel approach.

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