Thyroid eye disease

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This is a presentation related to thyroid eye disease for medical students and doctors. by RABIA FAROOQ, final year mbbs student at mohiuddin islamic medical college, mirpur, AJK

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Thyroid eye disease

  1. 1. THYROID EYE DISEASE GRAVE’S OPTHALMOPATHY
  2. 2. INTRODUCTION
  3. 3. INTRODUCTION--THYROID EYE DISEASE • Seen in 25 – 50% of graves disease. • GRAVES DISEASE also known as BASEDOW’S DISEASE is an autoimmune disorder that usually presents in 3rd to 4th decade of life, affects women more than men, characterized by a triad of features: • Hyperthyroidism • Diffuse thyroid enlargement • Opthalmopathy
  4. 4. INTRODUCTION -- TED • Thyroid eye disease (TED) may occur in the absence of clinical and biochemical evidence of thyroid dysfunction. • The occurrence of signs of graves disease in a patient who is not clinically hyperthyroid is referred to as euthyroid or ophthalmic graves disease. • Eye disease may be the first presenting sign of graves disease.
  5. 5. ETIOLOGY
  6. 6. ==GENETIC FACTOR ASSOCIATION: -- HLA DR3, CTLA-4, PTPN22 ( a T- cell regulatory gene). ==AUTOIMMUNE DISEASE ASSOCIATION: -- Myasthenia gravis, addison disease. ==RADIOACTIVE THYROID: Thyroid ablation with orally ingested radioactive iodine-131 may excerbate thyroid associated orbitopathy compared with anti-thyroid drugs and surgical ablation.
  7. 7. •STRONG ASSOCIATION OF THYROID EYE DISEASE WITH SMOKING
  8. 8. PATHOGENESIS
  9. 9. PATHOGENESIS • This involves an organ specific autoimmune reaction in which a humoral agent (IgG antibody) produces the following changes: • INFLAMMATION OF EXTRAOCULAR MUSCLES • INFLAMMATORY CELLULAR INFILTRATION
  10. 10. PATHOGENESIS: INFLAMMATION OF EXTRAOCULAR MUSCLES • Pleomorphic cellular infiltration, increased secretion of glycosaminoglycans,osmotic retention of water. • Muscles become enlarge( 8 times their normal size, may compress optic nerve). • Subsequent degeneration of muscle fibers eventually leads to fibrosis • Restrictive myopathy and diplopia.
  11. 11. HISTOLOGICAL PICTURE SHOWING ROUND CELL INFILTRATION OF EXTRA OCULAR MUSCLES IN THYROID EYE DISEASE
  12. 12. PATHOGENESIS: INFLAMMATORY CELLULAR INFILTRATION Infiltration with lymphocytes, plasma cells, macrophages & mast cells of interstitial fluid, orbital fat & lacrimal glands Increase in volume of orbital contents & secondary elevation of intraorbital pressure. Accumulation of glycosaminoglycans & retention of fluid. Secondary elevation of intraorbital pressure.
  13. 13. CLINICAL MANIFESTATION 5 main clinical manifestations of TED are: 1… SOFT TISSUE INVOLVEMENT (PERIORBITAL & LID SWELLING, CONJUCTIVAL HYPEREMIA. 2...LID RETRACTION 3…PROPTOSIS (PASSIVE OR MECHANICAL PROTRUSION OF EYE BALL) 4…OPTIC NEUROPATHY (SERIOUS COMPLICATION – COMPRESSION OF OPTIC NERVE MAY LEAD TO VISUAL IMPAIREMENT) 5…RESTRICTIVE MYOPATHY (OCULAR MOTILTY IS REDUCED INITIALLY BY INFLAMMATORY EDEMA & LATER BY FIBROSIS)
  14. 14. SYMPTOMS OCULAR SYMTOMS SYSTEMIC SYMPTOMS • • • • • • • • • • • • • • DRY EYES BULGING EYES DIPLOPIA VISUAL LOSS OCULAR PRESSURE OR PAIN PHOTOPHOBIA LACRIMATION TACHYCARDIA NERVOUSNESS HEAT INTOLERANCE INCRESE SWEATING WEIGHT LOSS IRRATIBILITY SKELETAL MUSCLE WEAKNESS
  15. 15. OCULAR SIGNS • PROPTOSIS ( eyes protude beyond orbit…unilateral or bilateral) • Exophthlmos (appearance of protuding eyes) • Conjuctival edema • Corneal ulceration • Visual impairement • Visual field defects • Papilloedema • Loss of colour vision • Opthlmoplegia • Optic disc usually normal • • • • • • • • • VIGOUROUX SIGN( eyelid fullness) DALRYMPLE SIGN( lid retraction in primary gaze) von GRAEFE SIGN( retarted descent of upper lid at downward gaze STELLWAG SIGN ( incomplete & infrequent blinking) GROVE SIGN( resistance to pulling down the retracted upper lid) JOFFROY SIGN ( abscent creases in forehead on sup. gaze) MOBIUS SIGN( poor convergence) BALLET SIGN ( restriction of one or more extra ocular movements) KOCHER SIGN ( staring & frightened appearance of eyes)
  16. 16. SEVERE BILATERAL PROPTOSIS & LID RETRACTION IN THYROID EYE DISEASE
  17. 17. PERIORBITAL SWELLING IN THYROID EYE DISEASE
  18. 18. LEFT EYE SHOW LID RETRACTION &MILD PROPTOSIS
  19. 19. von GRAEFE SIGN( RIGHT EYE)
  20. 20. KOCHER SIGN
  21. 21. RESTRICTED LEFT EYE ABDUCTION
  22. 22. SYSTEMIC SIGNS • FAST/ IRREGULAR PULSE • WARM MOIST SKIN • FINE TREMOR • PALMER ERYTHEMA • HAIR LOSS
  23. 23. DIFFERENTIAL DIAGNOSIS
  24. 24. DIFFERENTIAL DIAGNOSIS • ORBITAL CELLULITIS: Onset of proptosis is earlier & patient has other evidence of infection. (fever) • IDIOPATHIC ORBITAL INFLAMMATORY DISEASE: More painful than thyroid eye disease. • OTHER CAUSES OF THICKENED MUSCLES: sarcoidosis, amyloid, acromegaly.
  25. 25. INVESTIGATIONS
  26. 26. INVESTIGATIONS NON- SPECIFIC SPECIFIC • ROUTINE BLOOD PICTURE. • HAEMOGLOBIN. • WBC( total & differential count.) • ESR. • BLOOD SUGAR. • CHOLESTROL. • URINE EXAMINATION. *FOR HYPERTHYROIDISM: == SERUM T3 & T4 LEVEL ==SERUM TSH LEVEL. *FOR OCULAR MUSCLE ENLARGEMENT: ==PLAIN X-RAY CALDWELL VIEW(PA view) ==ORBITAL ULTRASOUND ==CT SCAN ORBIT ( AXIAL & CORONAL VIEW) ==MRI
  27. 27. Axial CT scan showing enlarged extra ocular muscles in thyroid eye disease
  28. 28. TREATMENT
  29. 29. GENERAL MANAGMENT CONTROL OF OCULAR DISCOMFORT =Artificial tears =Topical lubricants =Sunglasses ADVISE THE PATIENT TO =Avoid smoking as it worsens the prognosis =Avoid dust =Elevate head when sleeping to avoid periorbital edema
  30. 30. MEDICAL MANAGMENT CONTROL OF HYPERTHYROIDISM • Iodine and antithyroid drugs • Radioactive iodine ORBITAL DECOMPRESSION Systemic steroids: • Oral prednisolone: 60-80mg/day (dose should be tappered after reduction in symptoms) • I/V methylprednisolone: 0.5g in 200ml isotonic saline over 30 min(may be repeated after 48 hrs)
  31. 31. SURGICAL MANAGMENT Surgical treatment when there is severe sight threatening condition or for cosmetic purpose. ORBITAL DECOMPRESSION: (for advanced proptosis & optic nerve compression) STRABISMUS SURGERY: (to minimize diplopia) LID LENTHENING SURGERY
  32. 32. OTHER MANAGEMENT OPTIONS RADIOTHERAPY FUTURE OPTIONS • ORBITAL RADIOTHERAPY CAN BE USED TO TREAT OPHTHALMOPLEGIA BUT HAS LITTLE EFFECT ON PROPTOSIS. • THE RADIATION(1500-2000 Cgy fractioned over 10 days) IS USUALLY ADMINISTERED VIA LATERAL FIELDS WITH POSTERIOR ANGULATION • ANTI-TNF α ANTIBODIES(eg infliximab)

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