Thyroid ophthalmopathy is an autoimmune condition that can cause mild to severe and potentially sight-threatening eye disease. Graves' disease is the most common associated thyroid abnormality. Symptoms include eyelid retraction, proptosis, and restrictive myopathy. Signs include eyelid retraction in 91% of patients, proptosis in 62%, and restrictive myopathy in 42%. The condition is classified in several ways, including the Wernicke, CAS, VISA, and EUGOGO systems, which grade severity based on symptoms and signs.

1. Thyroid ophthalmopathy

2. • Self-limiting auto-immune process
• Mild to severe irreversible sight threatening
disease
• Graves' disease is the most common thyroid
abnormality
• Other associations include Hashimoto's
thyroiditis, thyroid carcinoma, primary
hyperthyroidism, and neck irradiation

3. EPIDEMIOLOGY
• Most common disease affecting the orbit
• Female to Male ratio 9.3:1 (mild cases) ;
1.4:1 (severe cases)
• Severe cases more frequent in >50 yr age
group
• Cigarette smoking is the strongest modifiable
risk factor

4. Etiology
• 80% are clinically hyperthyroid and 10% are
clinically euthyroid
• Associated with normal to abnormal thyroid
function
• In patients who are hyperthyroid, eye signs
usually develop within 18 months

5. PATHOGENESIS

7. Symptoms

8. SIGNS
• Eyelid Retraction (91%)
• Proptosis (62%)
• Restrictive Myopathy (42%)
• Soft Tissue Involvement
• Optic Neuropathy (6%)

9. LID RETRACTION
• increased sympathetic stimulation of Müller’s
muscle by thyroid hormone
• overaction of the levator muscle contracting
against a tight inferior rectus
• muscle scarring between the lacrimal gland
fascia and levator(lateral flare)

10. Proptosis
• Usually (90%) bilateral
• TAO is the most common cause of unilateral
and bilateral proptosis in adults
• Resulting from enlargement of the extraocular
muscles and adipose tissue, as well as orbital
fat deposits and the infiltration of orbital
tissues by GAGs and leukocytes.

11. • Severe proptosis prevents adequate lid
closure, and may lead to severe exposure
keratopathy and corneal ulceration.

12. Pseudoproptosis
• High myopia
• Congenital glaucoma (buphthalmos)
• Ipsilateral eyelid retraction
• contralateral enophthalmos
• Shallow orbit

13. Restrictive Myopathy
• Eye movements are restricted due to edema
in the extraocular muscles during the
infiltrative stage and the subsequent fibrosis.
• Despite expansion of the extraocular muscles
in TAO, the muscle fibers themselves are
normal.
• IR>MR>SR>LR

14. Clinical signs in TED
• Facial signs
–Joffroy’s sign-absent creases in the forehead on
superior gaze.

15. Eyelid signs
• Kocher’s sign-staring appearance
• Vigouroux sign-eyelid fullness

16. • Rosenbach’s sign-tremors of eyelids
• Riesman’s sign-Bruit over the eyelids
• Von graefe’s sign-lid lag on downgaze

17. • Dalrymple’s sign-lid retraction
• Stellwag’s sign-incomplete & infrequent blinking
• Boston sign-jerky movements of lid on downGaze
• Gellineck’s sign-abnormal pigmentation of upper
lid
• Gifford’s sign-difficulty in everting the upper lid

18. • Enroth ’s sign-edema of lower lid
• Griffith’s sign-lid lag on upgaze
• Goldzeiher’s sign-conjunctival injection

19. Extraocular movement signs
• Moebius sign-unable to converge eyes
• Ballet’s sign-restriction of one or more EOM
• Suker’s sign-poor fixation on abduction
• Jendrassik’s sign-paralysis of all EOM

20. CLASSIFICATION

21. Werners classification: NO-SPECS
• Class 0: No signs 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)

22. • Does not necessarily show sequential
involvement
• Inability to assess disease activity
• No prognostic or clinical implication

23. CLINICAL ACTIVITY SCORE
• In 1989, Mourits et al.developed the Clinical
Activity Score (CAS) for evaluating
ophthalmopathy activity.
• Found to be of value in predicting the
outcome of immunosuppressive treatment
and immunotherapy because of its high
specificity and high positive predictive value.
• CAS ≥4 were more responsive to treatment as
compared to patients with CAS<4

25. • 1. Pain on or behind the globe
• 2. Pain on eye movement
• 3. Redness of the eyelids
• 4. Redness of the conjunctiva
• 5. Swelling of the eyelids
• 6. Chemosis
• 7. Swollen caruncle
• 8. Increase of proptosis
• 9. Decreased eye movement
• 10. Decreased visual acuity

26. The VISA Classification
• Devised by Peter Dolman and Jack Rootman
• Based on four disease points
• Basic form consists of 4 sections recording
symptoms on the left and signs on the right
• Each disease activity is graded
• Objective and reproducible
• Appropriate management for patients in a
logical sequence

28. EUGOGO classification
EUROPEAN GROUP ON GRAVES
ORBITOPATHY
• MILD GO
– • minor lid retraction (<2 mm)
– • mild soft-tissue involvement
– • exophthalmos <3 mm above normal
– • no or intermittent diplopia
– • corneal exposure responsive to lubricants

29. • MODERATE GO
– • lid retraction ≥2 mm
– • moderate or severe soft-tissue involvement
– • exophthalmos ≥3 mm above normal
– • inconstant or constant diplopia

30. • SEVERE GO
– • DON and/or
– • corneal breakdown