thyroid eye disease
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The Eye & General Medicine
Exophthalmos & thyroid eye diseaseA case report for a ‘Grand Round’
Good Hope Hospital, March 2003
David Kinshuck, Associate Specialist, Eye Clinic
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, lipid accumulation, lymphocytes, fibrosis
• Pushes eye forward… exophthalmos
• Or presses on optic nerve (blindness)
• Eye movements reduced, squints
What is happening in the orbit
TSH receptors
orb ita l fa t/m uscle
ce ll (G raves d isease)
Receptors increase with smoking
Hypothroidism increases TSH
TSH receptors
Cell swells up with 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 year
activ ity
none sm oker, euthyro id
1 year
activ ity
activ ity increases TSH level
1 year
activ ity
activ ity trip les 20 cigs/day
What do we do in eye clinic
Note symptoms/appearance
Measure exophthalmos/TED group
What do we do in eye clinic
Note symptoms/appearance
Measure exophthalmos/TED group
Afferent pupillary defect
Test visual fields, colour vision, eye pressure, examine optic disc
What do we do in eye clinic
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
What do we do in eye clinic
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
Diagnose/treat ‘active’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.
PainPainful, oppressive feeling on or behind the globePain on attempted up, side, or down gazeRednessRedness of the eyelidsDiffuse redness of the conjunctivaSwellingChemosisOedema of the eyelid(s)Increase proptosis of 2 mm or more during a period between 1 and 3 monthsImpaired functionDecrease in visual acuity of 1 or more lines on the Snellen chart (using a pinhole) during a period between 1 and 3 monthsDecrease of eye movements in any direction equal to or more than 5 degrees during a period of time between 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 no
steroids• Depends on ‘activity’ 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 ‘severe’ cases are early on
1 year
activ ity
Threshold for steroids
1 year
activ ity
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 year
activ ity
Threshold for steroids
1 year
activ ity
Threshold for steroids
1 year
activ ity
Threshold for steroids
At onset difficult to judge outcome………………….
Our patient• Stable appearance for 2 years• Smokes, best to stop (may not make much
difference at this stage)• Offered referral for cosmetic surgery• Lid surgery (insert ‘spacer’ 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
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