Catastrophic Sequelae of Corneal Melt from Severe Active Thyroid Eye Disease in a Patient with Substance Use Disorder: A Case Report.

Introduction: Thyroid eye disease (TED) is a known complication of Graves' disease, but severe presentations with bilateral corneal melting ulcers are rare. Simultaneous substance use disorder might make the disease management more challenging. Case Presentation: Herein, we present a 29-year-old man with a history of Graves' disease who, despite prior hospitalization for milder symptoms, experienced a deterioration of his condition, leading to bilateral corneal melting ulcers. He was treated with fortified ophthalmic antibiotic drops, and methimazole dosage was increased. Intravenous methylprednisolone and mycophenolate mofetil were also started. Urgent orbital decompression on medial and inferior walls, canthotomy/cantholysis, and medial and lateral tarsorrhaphy were performed, followed by conjunctival flap placement and bilateral total blepharorrhaphy. Despite comprehensive treatment, the patient exhibited a poor therapeutic response and ultimately retained only light perception in both eyes. Conclusion: The patient's complex medical history including homelessness and substance abuse complicated both diagnosis and management. This case highlights the challenges in treating severe TED and underscores the importance of timely intervention and patient compliance.