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Thyroid eye disease

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  • 1. The Eye & General Medicine Exophthalmos & thyroid eye disease A case report for a ‘Grand Round’ Good Hope Hospital, March 2003David Kinshuck, Associate Specialist, Eye Clinic
  • 2. 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
  • 3. Appearance Upper lid retraction Lower lid retraction Exophthalmos (proptosis) Dry eyes Soft tissue lid swellingSymptoms Sore eyes/dry eyes/watery Appearance Optic nerve damage glaucoma
  • 4. 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
  • 5. What is happening in the orbit
  • 6. TSH Hypothroidismre c e p to rs increases TSH o r b ita lfa t/m u s c le c e ll (G ra v e s d is e a s e ) Receptors increase with smoking
  • 7. TSH re c e p to rs Cell swells upwith glcycoproteins etc
  • 8. What do we do in eye clinicHave to identify if active, and how active, and try and predict prognosis with and without
  • 9. a c tiv ity n o n e s m o k e r , e u th y r o id 1 year
  • 10. a c tiv ity a c tiv ity in c r e a s e s T S H le v e l 1 year
  • 11. a c tiv ity a c tiv ity tr ip le s 2 0 c ig s /d a y 1 year
  • 12. What do we do in eye clinic Note symptoms/appearance Measure exophthalmos/TED group
  • 13. 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
  • 14. 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
  • 15. 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
  • 16. 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 3monthsImpaired functionDecrease in visual acuity of 1 or more lines on the Snellen chart (using apinhole) during a period between 1 and 3 monthsDecrease of eye movements in any direction equal to or more than 5degrees during a period of time between 1 and 3 months(From Mourits et al)
  • 17. 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
  • 18. 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
  • 19. • 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 Threshold fora c tiv ity steroids 1 ye a r
  • 20. Threshold fora c tiv ity steroids Thyroid eye 1 year Red=very active=proptosis/optic atrophy disease activity black=intermediate=some proptosis score green=soft tissue changes that will resolve
  • 21. Threshold fora c tiv ity steroids 1 year
  • 22. Threshold fora c tiv ity steroids 1 year
  • 23. Threshold fora c tiv ity steroids 1 year At onset difficult to judge outcome………………….
  • 24. 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
  • 25. 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