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8/4/2019 Thyroid Eye Disease by Abhishek Jaguessar
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The Eye & General Medicine
BY
ABHISHEK JAGUESSAR
8/4/2019 Thyroid Eye Disease by Abhishek Jaguessar
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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
8/4/2019 Thyroid Eye Disease by Abhishek Jaguessar
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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
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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
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What is happening in the orbit
8/4/2019 Thyroid Eye Disease by Abhishek Jaguessar
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TSHreceptors
orbital
fat/muscle
cell
(Graves
disease)
Receptorsincrease with
smoking
Hypothroidism
increases TSH
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TSHreceptors
Cell swells upwith glcycoproteins
etc
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What do we do in eye clinic
Have to identify if active, and how active, and
try and predict prognosis with and without
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1 y r
cti ity
n n s k r, thyr i
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1 y r
cti ity
cti ity incr s s T l l
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ear
activit
activit triples 20 cigs/da
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What do we do in eye clinic
Note symptoms/appearance
Measure exophthalmos/TED group
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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
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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
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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 µactive¶disease
& inactive disease..eg lid/squint
surgery
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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)
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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
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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
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� 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
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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
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1 ear
activit
Threshold
for
steroids
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1 ear
activit
Threshold
for
steroids
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1 ear
activit
Threshold
for
steroids
At onset difficult to judge outcome«««««««.
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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
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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