A 42-year-old man was referred to our hospital for recurrent episodes of conjunctivitis and episcleritis that did not improve with conventional treatment.
He reported no personal or ophthalmological history of interest, only a smoking habit of approximately one pack a day.
On ophthalmological examination, corrected visual acuity (VA) was unity in both eyes; biomicroscopic findings included conjunctival injection and chemosis +/+++, upper eyelid oedema and lower superficial punctate keratitis. There was no palpebral retraction or exophthalmos and intraocular pressure (IOP) was 13/11 mmHg. Classification according to the NONSPECS index of 2-b, 5-a.
Basic laboratory tests (biochemistry and haemogram) were normal, thyroid hormones (T3,T4,TSH) were elevated. The patient was referred to the endocrinologist with a diagnosis of mild-moderate OG in the active phase, who started antithyroid treatment together with topical ocular ophthalmological treatment.
Subsequent examinations revealed progression of the ophthalmopathy to a moderate-severe stage with worsening of the biomicroscopic signs, development of upper palpebral retraction of 3 mm in both eyes and lower retraction of 2 mm in the right eye (OD) and 1 mm in the left eye (OI), Hertel exophthalmometry of 25 mm in the OD and 24 mm in the OI and increased IOP (24/22 mmHg). An octreoscan was performed, consisting of an injection of 6 mg of intravenous In111-octreotide and planar imaging with photon emission tomography at 4 and 24 hours. These images revealed the presence of activity at the orbital level using a qualitative contrast method comparing the uptake with the background (occipital bone tissue), so treatment was started with lanreotide 90 mg every 3 weeks for 2 months, followed by 60 mg intramuscular every 15 days for a further 2 months.

After treatment, the test was repeated and a decrease in orbital uptake was observed. The corrected VA was 1 in the OD and 0.9 in the OI, with mild inferior corneal epitheliopathy persisting. IOP was 17/14 mm Hg with topical hypotensive treatment in the OD and trabeculectomy in the LA (one month after starting treatment) due to sustained hypertension (≈36 mm Hg) with no response to medical treatment. Exophthalmometry of 22 mm AO and upper palpebral retraction of 2 mm and lower of 1 mm AO awaiting surgical correction.

