Thyroid Eye Disease (TED) is an autoimmune condition that causes inflammation of the muscles and fatty tissues around the eyes. It is often associated with Graves' disease of the thyroid gland. Common signs include bulging of the eyes, dry eyes, swelling of eyelids, and double vision. The condition progresses through active and stable phases, with the active phase characterized by worsening inflammation and swelling lasting around 1 year for non-smokers and 2-3 years for smokers. Treatment depends on the severity and includes medications, orbital radiation, or surgery to repair eye muscle damage or remove fat behind the eyes.

1. Thyroid Eye Diseases (TED)
Md . Azizul Islam
Junior Optometrist
Ispahani Islamia Eye Institute & Hospital
IIEI&H
e-mail : ajijulislam513@yahoo.com
Twitter : @ajijulislam513
LinkedIn : Slideshare.net/AzizulIslam6

2. Declaration …
I have no financial interest by
presenting this presentation
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3. Aims of today,s topic
 Will be able….
• General idea @ Endocrine glands
• To know about Thyroid gland
• To know about Thyroid Eye Diseases (TED)
• Clinical Manifestation of TED
• Clinical Activity Score of TED
• How to Documentation TED finding
• Clinical Examination of TED
• Clinical Investigation of TED
• Treatment of TED
• Home Message
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4. Thyroid Eye Diseases often termed as Graves ophthalmopathy, is
a part of an autoimmune process Endocrine glands that can
affect the orbital and periorbital tissue, the thyroid gland and
rarely the pretibial skin or Orbital fat .
Synonyms are :
 Graves Orbitopathy
 Graves Eye Diseases
 Graves Ophthalmopathy
 Thyroid Associated Ophthalmopathy
 Thyroid Exophthalmos
 Vons Basedow`s
{Carl Adolph von Basedow (1799-1854)}
Thyroid Eye Diseases (TED)
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5. Endocrine glands are glands of
the endocrine system that secrete their
products, hormones, directly into the blood
rather than through a duct. The
major glands of the endocrine system
include the pineal gland,Hypothalamus,
Pituitary gland, Thyroid gland,Parathyroids,
Thymus,Adrenals,Pancreas, Ovaries &
Testes
Endocrine Glands
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6.  The pineal gland is located in the diencephalon of the brain. It primarily
releases melatonin, which influences daily rhythms and may have
an antigonadotropic effect in humans
 The Thyroid gland is one of the largest endocrine glands. it is a small, butterfly-
shaped gland ,located in the base of the neck just below the Adam's apple
 The parathyroid glands, of which there are 4-6, are found on the back of the thyroid
glands, and secrete parathyroid hormone (PTH)
 The adrenal glands are located above the kidneys in humans and in front of the
kidneys in other animals. It controls the behaviour during crisis and emotional situations
 The Thymus glands is a small organ that lies in the upper chest under the breastbone.
It makes white blood cells, called lymphocytes, which protect the body against infections.
 The pancreas, located in the abdomen, below and behind the stomach, is both
an exocrine and an endocrine gland
 Gonads is the ovaries of the female, located in the pelvic cavity, release two main
hormones
Endocrine Glands
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7. The thyroid gland is one of the largest
endocrine glands. it is a small, butterfly-shaped
gland ,located in the base of the neck just below
the Adam's apple. Although relatively small, the
thyroid gland plays a huge role in our body,
influencing the function of many of the body’s
most important organs, including the heart,
brain, liver, kidneys and skin. Ensuring that the
thyroid gland is healthy and functioning
properly is vitally important to the body's
overall well-being
The Thyroid Gland
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8. The presence and diseases of the thyroid have been noted and treated for thousands of years
 The book Sushruta Samhita written about 1400 BCE describes hyperthyroidism,
hypothyroidism and goiter
 “Aristotle and Xenophon” in the 15th century BCE describe cases of Grave's disease
 In 1500 polymath ”Leonardo da Vinci” provides the first illustration of the thyroid
 In 1543 Anatomist ”Andreas Vesalius ”gave the first anatomic description and illustration
of the gland
 In 1656 the thyroid received its name, by the anatomist ”Thomas Wharton.”
 French chemist ”Bernard Courtois” discovered Iodine in 1811
 Grave's disease descriptions provided by” Robert James Graves” in 1834
 ”David Marine” in 1907 provided iodine is necessary for thyroid function.
 Thyroxine itself was first isolated in 1914 and synthesized in 1927, and triiodo thyroxine
in 1952. The conversion of T4 to T3 was discovered in 1970
History of Innovation Thyroid

9.  Hypothalamic Step: The hypothalamus releases Thyrotropin-
releasing Hormone (TRH) which acts on the anterior pituitary. It
should be pointed out that TRH is also involved in the regulated
release of prolactin
 Pituitary Step: Upon being stimulated by TRH, the anterior
pituitary synthesizes and secretes Thyroid Stimulating Hormone
(TSH) which acts directly on the thyroid gland
 Thyroid Step: Upon being stimulated by TSH the thyroid gland
releases thyroid hormones
 Tissue Step: Recall from Thyroid Hormone Synthesis that the
thyroid gland mostly releases T4 which does not possess much
endocrine activity. Target tissues possess the enzyme Iodinase that
converts T4 to either T3 or rT3. T3possesses tremendously more
endocrine activity than T4 whereas rT3 does not possess any
endocrine activity
Regulation of Secretion of
Thyroid Hormone
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10. Hypothyroidism Hyperthyroidism
Symptoms of Thyroid
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11. Graves' disease (TAO/TED):- The production of too much thyroid hormone.
Goiter :- Enlargement of the thyroid gland
Hyperthyroidism :- When your thyroid gland makes more thyroid hormones
than your body needs
Hypothyroidism :- When your thyroid gland does not make enough thyroid
hormones
Thyroid cancer:- Thyroid cancer frequently presents without any symptom.The
most common symptom is a lump in the neck.
Thyroid nodules :- Lumps in the thyroid gland
Thyroiditis :- Swelling of the thyroid
Toxic adenomas:- Nodules develop in the thyroid gland and begin to secrete
thyroid hormones, upsetting the body's chemical balance
Thyroid Diseases
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12. Enlarged Thyroid Glands
Forward Protution of Eyeball
Thyroid Cancer Thyroid Goiter
Thyroid Diseases
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13. Thyroid Eye
Disease
(TED) …..
Now We Comeback @
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Again..!

14. Over all Thyroid eye disease (TED) is an eye
condition in which the eye muscles and fatty
tissue behind the eye become inflamed. This
can cause the eyes to be pushed forward
(‘staring’ or ‘bulging’ eyes) and the eyes and
eyelids to become swollen and red. In some
cases there is swelling and stiffness of the
muscles that move the eyes so that the eyes are
no longer in line with each other; this can cause
double vision. Rarely TED can cause blindness
from pressure on the nerve at the back of the
eye or ulcers forming on the front of the eyes
Thyroid Eye Diseases (TED)
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15. TED is the most common cause of both orbital disease and
exophthalmos (external protrusion of the eyeball from the socket) in
North America and Europe.TED occurs more frequently in women
than in men, with both sexes having two age ranges in which TED is
most likely to be diagnosed
 Females
• 16 per 100,000 (0.016%) females have TED
• Most diagnoses occur between 35-44 and 60-65 years old
 Males
• 3 per 100,000 (0.003%) males have TED
• Most diagnoses occur between 45-49 and 65-69 years old
 Paediatric
• 2 per 100,000 (0.002%) Children have TED
• Most diagnoses occur between 4 Months-17 years old
Epidemiology of TED
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16. Signs & Symptoms of TED
Upper and/or lower eyelid retraction :-The eyelid is pulled away from its
normal resting position
 Exophthalmos/Proptosis:- Bulging of the eyeball out of the eye socket
Globe Displacement:- Dysplasia
Restrictive extraocular myopathy :- Swelling of the muscles that control eye
movement resulting in inadequate mobility of the eyes
 Pain with eye movement :-Affects about 30% of TED patients
Optic nerve dysfunction / compressive optic neuropathy:- Affects about 6%
of TED patients
Warning signs include :-
• Decrease or change in color vision
• Decreased peripheral vision
• Decreased crispness of central vision
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17. Signs & Symptoms of TED
Pain on or behind the globe
Swelling in and around the eye socket
Strabismus (the eyes are not in alignment with each
other) and diplopia (double vision)
Dry, irritated, red eyes
Lagophthalmos is the inability of the eyelid to fully close
Chemosis is swelling within the conjunctiva
Swelling of the caruncle (the red prominence at the inner
corner of the eye)
Eyelid swelling & Eyelid erythema
Conjunctival injection
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18.  Bulging of the eyeball
 Conj:Chemosis
 Conjunctival injection
 Lower Eyelid Retraction
 Swelling of the Caruncle
Signs & Symptoms of TED

19. To grade the severity of TED:
 Class 0: No signs or symptoms
 Class 1: Only signs (upper lid retraction)
 Class 2: Soft tissue involvement (swelling of the eye or tissues
surrounding the eye)
 Class 3: Proptosis (bulging of the eye out of the eye socket)
 Class 4: Extraocular muscle involvement (usually with strabismus)
 Class 5: Corneal involvement (severe dry eye from inability to
adequately close the eye)
 Class 6: Sight loss (due to optic nerve involvement)
Clinical Manifestation
(TED): NO-SPECS
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20. Lid Retraction
Soft tissue involvement
Proptosis
Clinical Manifestation Signs
Extraocular muscle involvement
Optic nerve involvement
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21. Risk factors for the development of TED include the following…
 Sex (females more likely to be diagnosed with TED)
 Ethnicity (higher incidence among people of black and Asian/Pacific Island
ethnicity
 Family history of TED or other thyroid disorders
 Smoking, or exposure to tobacco smoke
 N.B: Smoking or exposure to cigarette smoke Smokers are twice as likely to
develop Graves' disease Smokers with Graves' disease are over 7x more likely to
develop TED, when compared to nonsmokers Smokers tend to have a longer
duration of the active phase of TED (2-3 years for smokers,
compared to 1 year for nonsmokers)
Risk factors of TED
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22. Tobacco smoke contains substances that affect both the
function of the thyroid gland. One of the components of
tobacco is cyanide which, when the smoked, is converted to
the chemical thiocyanate. Thiocyanate is known to interfere
with thyroid function in three key ways:
 It inhibits the uptake (absorption) of iodine into the thyroid
gland, reducing the production of the thyroid hormones
thyroxine (T4) and triiodothyronine (T3).
 It directly inhibits hormone production by interfering with
the synthesis process in the thyroid gland.
 It increases the excretion of iodine from the kidneys,
increasing the risk of thyroid gland inflammation.
Smoking VS TED
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23.  The disease course for TED involves 2 phases - active
and stable. In the active phase there is active swelling
and inflammation. This presents as redness in and
around the eye, eye pain with or without eye movement,
as well as swelling around the eyes and eyelids. The
active phase of TED involves a waxing/waning period
of these symptoms, and can last months to years. On
average, the active phase of TED lasts about 1 year for
non-smokers, and 2-3 years for smokers (or patients
exposed to smoke)
Disease Course for TED
 The active phase of TED spontaneously transitions to the stable phase, but can recur.
Active TED has a recurrence rate of about 5-10%, but is less likely to recur after 18
months in the stable phase
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24. HISTORY
LOCAL
EXAM:
SYSTEM
EXAM:
INVESTI
GATION
IMAGING
Examination of TED
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25. History Taking For TED
 Protrusion of eyeball: Age of Onset , duration , progression, Constant
or intermittent, Variation with posture / strain
 Decreased vision : Preceded, Stationary, Associated field defects
 H/O: Pain
 H/O :Double vision
 H/O: Fever , Systemic Symptoms
 H/O :Thyroidectomy
 H/O :Weight loss
 H/O: Sweating
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26. Local Examination of TED
 HB Reflex : Central or Deviation
 Globe Displacement: Downward,Upward or Other
 Lid Retruction: +(ve) or – (ve)
 Lid lag/Lagophthalmos: ..? mm
 Palpation : Size , Shape, Surface, Margins consistency ,
Tenderness , Thyroid glands (Nodule), Orbital rims , Regional
Lymph nodes.
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27.  EOM : Decreased / Restricted/Ophthalmopleagia
 VA : Maybe decreased due to Refractive changes due to pressure on
eyeball, Optic nerve compresssion, Exposure keratopathy
 Pupillary Reaction : RAPD suggests optic nerve compression
 IOP : Should Measurement at primary position & Up Gage Position.
 Ruler Test: Hertels exophthalmometer + Horizontal with vertical
measurement (Measurement of proptosis)
Local Examination of TED
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28. Case 01: TED
Name : Mrs. Fatema Begum , Age 65 Yrs
C/C: Forward bulging BE for 16-17 yrs.
Swelling around side B/E (L>R)
Redness,Pain,Watering, Burning Sensation LE For 2-3
Months.
VA> RE= 6/18 PH 6/9 , LE= 6/60 PH 6/24
IOP > RE 21, LE 23 mmHg
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29. Documentation of Case :01
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30. Documentation of Case: 01
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31. Case 02: TED
Name : Mrs. Kiron Begum , Age 36 Yrs
C/C: Soft tissue around side B/E with Forward Bulging BE
(R>L) for 6 Days. Dimness of vision B/E (R>L).
Pain,Watering ,Discharge B/E .
H/O: Weight loss about 15-16 kg last 5-6 months .
Palpitation Sweating ,Diarrhoea
VA> RE= 1/60 , LE= 6/12p
IOP >Not Record
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32. Documentation of Case :02
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33. Documentation of Case :02
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34. Imaging:
 USG/ CT-Scan/ MRI/ X-Ray/Thyroid Scan
 Brain Scan,Whole body Scan,Liver Scan
Functional:
Thyroid function test: FT3,FT4,T3,T4,TSH
 Incisional biopsy
 Excisional biopsy
Core biopsy
Hematological : CBC , ESR, VDRL
FNAC
Investigation
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35. Management of TED:
 Local Management: Sun glasses, Sleep in supine position with head
elevated,Taping of lids at night, Prisms in diplopia.
 Medical Therapy: Topical tear substitutes, Systemic diuretics - Minimal
role,Parenteral antibiotics & Punctum Plugs implantation for Dry Eyes.
 Anti Thyroid: Have many beneficial properties in treating TED,
 Hyperthyroidism>Carbimazole (CMZ)( Tab:Carbizole/Carbiroid)&
 Hypothyroidism> Levothyroxine Sodium (Tab:Thyrox/Thyrotab)
 Oral NSAIDs for eye pain
 Radiation:Orbital Radiotherapy (ORT) & Chemo Therapy (Pseudo tumour,
Lymphoma, Rhabdomyosarcoma , Meningioma,Thyroid orbitopathy ).
 Surgical options: Orbitotomy, Orbital decompression, Thyroidectomy,
Tarsorrhaphy (Medial+Lateral)
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36. Take Home Messages
 There is now a lot that can be done to help people with TED, from
artificial tear drops to surgery
 Smoking increases your chance of getting TED. Patients with TED who
continue to smoke respond less well to treatments. Please stop
Smoking
 Avoid fluctuations in your thyroid levels – have regular blood tests and
take your medication regularly
 TED can affect our psychological and social well-being.
 Refer your patient to a specialist eye Centre which has experience of
thyroid eye disease, especially if the symptoms become more severe
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37. References
 Thyroid Eye Disease, Author : Devron H.Char
 The Thyroid Eye Disease Book: Understanding Graves,
Author : Elaine Moore
 Essentials of Medical Physiology,K Sembulingam &
Prema Sembulingam
 http://www.british-thyroid-association.org
 Picture: Me ,Google.
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39. If Any Question
Please……
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