Thyroid Eye Disease by Abhishek Jaguessar

8/4/2019 Thyroid Eye Disease by Abhishek Jaguessar

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The Eye & General Medicine

BY

ABHISHEK JAGUESSAR



Case: Thyroid eye disease

(Graves)� 46y female

� 1998 (41y) thyrotoxicosis,

treated with antithyroid drugs

� 1999 radioactive iodine (systemic steroids 2 months)

� 2001 exophthalmos, active, referred

� 2003 stable, but expecting treatment� Unhappy with appearance

� Sore gritty watery eyes



Appearance

Upper lid retraction

Lower lid retraction

Exophthalmos (proptosis)

Dry eyes

Soft tissue lid swelling

Symptoms

Sore eyes/dry eyes/watery

Appearance

Optic nerve damage

glaucoma



Pathology, basis

� Enlarged ocular muscles &soft tissues

� Glycoproteins accumulate

inside cells, lipidaccumulation, lymphocytes,fibrosis

� Pushes eye forward«exophthalmos

� Or presses on optic nerve(blindness)

� Eye movements reduced,squints



What is happening in the orbit



TSHreceptors

orbital

fat/muscle

cell

(Graves

disease)

Receptorsincrease with

smoking

Hypothroidism

increases TSH



TSHreceptors

Cell swells upwith glcycoproteins

etc



What do we do in eye clinic

Have to identify if active, and how active, and

try and predict prognosis with and without



1 y r

cti ity

n n s k r, thyr i



1 y r

cti ity

cti ity incr s s T l l



ear

activit

activit triples 20 cigs/da




Note symptoms/appearance

Measure exophthalmos/TED group






Afferent pupillary defect

Test visual fields, colour vision,

eye pressure, examine optic disc









CT scan..diagnosis, especially if

unilateral









CT scan..diagnosis, especially if

unilateral

Diagnose/treat µactive¶disease

& inactive disease..eg lid/squint

surgery



Proposed Classification System to Assess Disease Activity in

Thyroid Eye Disease. One point is given for each sign present.

Pain

Painf l, r ssi f lin n r hin th l

Pain n att t , si , r wn aze

Redness

Redness f the eyelids

Diff se r edness f the c nj ncti a

SwellinChemosis

Oedema of the eyelid(s)

Incr ease r optosis of mm or mor e durin a period etween 1 and 3

months

Impair ed f unction

Decr ease in isual acuity of 1 or mor e lines on the Snellen chart (usin a

pinhole) durin a period etween 1 and 3 months

Decr ease of eye movements in any dir ection equal to or mor e than 5

degr ees during a period of time etween 1 and 3 months

(From Mourits et al)



Signs of activity:

� Puffiness increasing

� exophthalmos increasing

� pain increasing

� patient is reasonable judge

� optic nerve compression/field loss

� diplopia beginning

� all this early on in disease, unusual after 1 year



Treatment in active phase� If active AND sight threatened, or proptosis

disfiguring, systemic steroids

(or it is reasonably clear this is likely)� If activity continues despite steroids, radiotherapy

to orbits

� Can decompress orbit surgically as alternative

� Soft tissue activity only, no proptosis, so nosteroids

� Depends on µactivity¶ score



� Can be difficult to determine whether

disease is active

� Best results are when (severe cases) are

given steroids early

� Don¶t really know which the µsevere¶ cases

are early on

1 y e a r

a c t iv i ty

Threshold

for

steroids



1 ear

activit

Threshold

for

steroids

Thyroid eye

disease activity

score

Red=very active=proptosis/optic atrophy

black=intermediate=some proptosis

green=soft tissue changes that will resolve



1 ear

activit

Threshold

for

steroids



1 ear

activit

Threshold

for

steroids

At onset difficult to judge outcome«««««««.



Our patient

� Stable appearance for 2 years

� Smokes, best to stop (may not make muchdifference at this stage)

� Offered referral for cosmetic surgery

� Lid surgery (insert µspacer¶ material)

� possibly orbit surgery, more complex/risky



Illustrates problems in medicine (life)

generally

� Treatments get more effective, more is known,making tremendous progress

� powerful treatments, side effects,

� often hard to decide at the time what to do

� sub-specialty training helps, but patients will not present to the expert initially

� treatment windows:

leaving things late causes problems� hard data lacking: cannot be trained for all problems

Thyroid Eye Disease by Abhishek Jaguessar

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