1.
TED EVALUATION
- ANURAG SHUKLA
Fellow optom.
Dr. shroff charity eye hospital,Delhi

2.
Contents..
THYROID GLAND :
Largest gland in the body
Shape : Butterfly like structure
Position : in the front of the neck.
Function : controls the hormones and metabolic
activity in the body.
Release hormone: T3 , T4 ( T1+T2+Iodine)

3.
Contents..
THYROID GLAND :
Hypothyroidism:
the thyroid produces too little hormones. If the
body doesn’t get enough hormones, you may get
tired, experience depression, have dry skin, gain
weight, become forgetful, and become weak.
Hyperthyroidism :
In this disorder, the thyroid gland produces too
much. These conditions can cause a fast heart
rate, no ability to rest, feeling too hot and the
need to poop often. Hyperthyroidism is more
common in women than in men.
Excess iodine may cause hyperthyroidism.

4.
TRH : senses the body needs thyroid hormone.
(Hypothalamus to Pituitary gland)
TSH : to produce thyroid hormones including both T3 & T4.
(Pituitary gland to Thyroid gland)
Thyroxine ( T4 ) : storage hormone
Triiodothyronine ( T3) : active hormone
Reverge T3 : block T3 cellular receptor sites and inhibit
conversion of T4 to T3

5.
Thyroid hormones
• Thyroid hormones target almost every body cell
• Can enter cells & bind to intracellular receptors on mitochondria & in
nucleus
• Effects include:
• increased ATP production
• increased cellular metabolism, energy utilization & oxygen consumption ,
increase blood flow
• increased body temperature
• growth & development of skeletal, muscular & nervous system in fetus &
children

6.
Epidemiology
• unilateral and bilateral
• Higher prevalence in women than men (16 per 100,000 vs. 3 per 100,000,
respectively)
• A positive family history of TED is noted in 61% of TED patients.
• associated with both genetic and environmental factors such as cigarette
smoking, and stress.

7.
Risk factor
• Smoking
• Family history
• Myozygomatic twins

8.
Progression of TED After treatment
%ProgressionofTED
23%
6%
Bartalena, Ann Intern Med, 1998

9.
How to interpretate thyroid report
• Normal range :
TSH : 0.4 – 3.8 microIU/ml
T4 : 4.4-12.5 microgram
T3 : 0.9- 1.95 ng/ml
TSH Test : ↑ TSH = Primary hypothyroidism
↓ TSH = Hyperthyroidism
↓ TSH = Secondary hypothyroidism
: A normal TSH value : thyroid is functioning properly.

10.
• T4 test :
– ↑ TSH + ↓ T4 = primary hypothyroidism
– ↓ TSH + ↓ T4 = Secondary hypothyroidism
– ↓ TSH + ↑ T4 = Hyperthyroidism
• T3 test : useful to diagnosis and determine the severity of hyperthyroidism.
• ↑ T3 = hyperthyroid
• ↑ TSH + ↓ T4 + normal T3 = severely hypothyroid.

11.
Reports for interpretation

12.
symptoms
• Dryness or frequent blinking
• Cosmetic complain : bulging eye
• Diplopia
• Redness
• Visual impairment
• Pain

13.
Ocular Sign
1. Upper eyelid retraction – the most common presenting sign of TED
• Up to 90% of patients affected (bilateral or unilateral)
• Physical exam:
• Dalrymple’s sign : scleral show inf. & sup.
• Lagophthalmos
• Temporal flare : elevation of the temporal
portion of the upper eyelid.

14.
Sign of TED
2. Exophthalmos:
• the second most common sign associated with TED
• 60% of patients are affected
• Globe subluxation: anterior displacement of the globe
• Anoxic destruction of the optic nerve can cause
irreversible visual loss

15.
3. EXTRAOCULAR MYOPATHY:
• 40% of patients affected
• Inferior and medial rectus muscles
most commonly affected, leading to
hypotropia and esotropia, respectively
Sign of TED

16.
Sign of TED
Other common signs:
– eyelid lag
– Pain with eye movement
– optic neuropathy
– Chemosis
– conjunctival injection
– RAPD

17.
Severity of TED: NO-SPECS
THE WARNER’S GRADING :
• Class 0: No sign or symptoms
• Class 1: Only signs (lid retraction, stare ± lid lag)
• Class 2: Soft tissue involvement
• Class 3: Proptosis
• Class 4: Extraocular muscle involvement
• Class 5: Corneal involvement
• Class 6: Sight loss (optic nerve involvement)

18.
CLINICAL ACTIVITY SCORE : INITIAL VISIT
3
2
1
6
4
7
Conjunctival injection
Active*
Chemosis
Inflammation of caruncle
Add your words here
Eyelid swelling
Gaze evoked orbital pain
orbital pain
in the last 4 weeks
Active*
DISEAES
ACTIVITY
Eyelid erythema
5
in the last 4 weeks

19.
CLINICAL ACTIVITY SCORE
FOLLOW UP VISIT
At follow‐up visits, add the 3 following criteria for a potential CAS score of 10
• Increase of ≥ 2 mm in proptosis
• Decrease in uniocular motility in any one direction of ≥ 8 degrees
• Decrease in visual acuity equivalent to 1 Snellen line
TED is considered “active” if the CAS ≥ 3 at the initial visit or ≥ 4 at follow‐up visits.
ACTIVE PHASE STABLE PHASE

20.
VISA Classification
• Developed by Dolman and Rootman in 2006
• modifications by the International Thyroid Eye Disease Society (ITEDS)
• The system assesses 4 severity parameters:
 V = vision
 I = inflammation or congestion
 S = strabismus/motility restriction
 A = appearance/exposure

21.
VISA
Classification
maximum score is 20 points
Vision : 1 point
Inflammation : 10 points
Strabismus /motility : 6 point
Appearance /exposure : 3

22.
1.Vision
(VISA Classification)
• Vision (V) evaluates the visual repercussion particularly
– Vision
– Color vision
– Retinal pathology
– pupillary reflexes
– Contrast

23.
inflammation/congestion
(VISA Classification)
Inflammatory index :
• Score less than ≤ 4 : managed conservatively. (cool compresses, nocturnal head elevation,
and NSAID)
• Score ≥ 5 : aggressive therapy (oral / IV corticosteroids, radiotherapy, immunosuppressive agents.)

24.
Inflammatory grading
• Chemosis grading :
grade I - behind the gray line of lid.
grade II- extend anterior to the grey line.
• Lid edema:
grade I -present but without redundant tissues
grade II -bulging in the palpebral skin + lid festoon.
VISA inflammatory
Score: 9/10
Post IV 1 gm
methylprednisolone:
VISA inflammatory
score = 3/10

25.
Strabismus /motility
(VISA Classification)
•Accurate assessment of changes in ocular ductions : identify progression , management,
and response to therapy assessment.
•change of ≥12 degree : considered progression

26.
• Ocular ductions : can be graded from 0 to 45 in four directions using the
Hirschberg principle.
• Strabismus can be measured objectively by prism cover testing.
• Management of strabismus:
• Manage the progression & inflammation first is present.
• management of strabismus might include prisms or surgical alignment
Strabismus/ocular motility

27.
appearance/exposure
(VISA Classification)
•Appearance : bulging eyes, eyelid retraction, and fat pockets
•ocular exposure : gritting sensation, photophobia, dryness, and secondary tearing
•Signs include measurements : eyelid retraction, scleral show , levator palpebrae superioris function,
proptosis.
•Signs of corneal exposure : punctate epithelial erosions, ulcerations, and, in severe cases corneal thinning
and risk of perforation.

28.
Management of appearance and exposure
• depend on the inflammatory stage of the disease.
• lubricant drops and ointments can relieve ocular
irritation.
• Tarsorrhaphy / orbital decompression
Pre & post orbital decompression

29.
EYELID RETRACTION
• Normally, upper eyelid- 2mm below limbus
lower eyelid-inferior limbus.
• When retraction occurs, the sclera (white)
can be seen
• Due to increased sympathetic stimulation
of Müller’s muscle by thyroid hormone.
• Scleral show between corneal limbus and
either eyelid margin
Eyelid retraction +
Scleral show

30.
Upper eyelid position : MRD- I
• Distance between the upper Eyelid
margin to CLR.
• Normal : 4 – 4.5 mm

31.
PROPTOSIS EVALUATION
• the Hertel’s exophthalmometer is the most
commonly used instrument to measure
proptosis.
• The distance between the lateral orbital rim
and the corneal apex is used as a measure for
proptosis.
• Normal values vary between 10 and 21 mm
and are symmetrical in both eyes.

32.
Method
• Pt to look stright ahead
• Palpate the bony ridge
– Locating deepest angle of the orbit.
• Loose the lock
– slide mirrors or prisms along the horizontal bar to adjust
footplates with corresponding lateral orbital rims
• • Bring Hertel forward toward pt, keeping it parallel
to floor with crossbar scale visible in front
• • pt eye should be closed

33.
• Position footplates against each lateral orbital
rim independently
• pts eye open widely & at your eye level
• Look at the mirror
– Take mm measurement where apex of cornea(lower)
is superimposed on the mm scale (upper)
• corneal reflex lower mirror & mm scale upper
mirror.
• Read of the cross bar scale (near BASE)

34.
interpretation
• Relative :
• comparison of readings b/t two eyes
– normal: </= 2mm
• Absolute :
• comparison of readings to norms
• whites 12 to 20 mm1 (10-22mm)
– average 15 -17mm
• blacks 12 to 24 mm
– average 2mm higher than whites

35.
• Test for tear quantity (aqueous level)
• Based on wetting length of the strip 5x35mm Whatman
41 filter paper
• Placed in the lower fornix 2/3rd from medial canthus and
1/3rd from lateral
• 2 variations :
– Schirmer 1(with anaesthetic) – basal secretion
– Schirmer 2(without anaesthetic) – basal + reflex secretion
Schirmer’s test

36.
• Measures total tear secretion (basic and reflex)
• Open eye technique
• Normal :10-30 mm at the end of 5min
• If wetting >30mm before 5 min
– Reflex tearing overactive/ insufficient tear drainage
• Value < 5mm Hyposecretion
Interpretation

37.
• Determine by the lid excursion caused by LPS muscle.
• METHOD:
• Asked to pt look down
• Place the thumb against the eyebrow (to block frontalis)
• Then look up
• Amount of upper lid excursion Measure with the ruler.
• Result:
– 15 mm Normal
– ≥ 8 mm good
– 5-7 mm fair
– ≤ 5 mm poor
LEVATOR FUNCTION TEST

38.
• Distance between the upper and lower lid margin.
• Normal :
– Male : 7-10 mm
– Female : 8-12 mm
• Normally : upper lid 2mm below the sup. Limbus.
lower lid just below the inf. limbus
Palpebral fissure height

39.
• Inability to complete close of eyelid.
• Method :
• Asked to pt close the eye gently.
• Measure the exposed area with ruler.
complication :
Corneal exposure , dryness,
corneal abberation
Lagophthalmos measurement
Lagophthalmos +

40.
THANK YOU !