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Similar to Thyroid associated orbitopathy of dr. sohel mahmud
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Thyroid associated orbitopathy of dr. sohel mahmud
- 1. Thyroid associated orbitopathy Presentation is made by Dr. Sohel Mahmud MBBS, DO. Eye specialist & surgeon Dhaka, Bangladesh. A stone made statue of a man with unilateral proptosis at the time of ancient Greece.
- 3. Introduction cont... Thyroid-associated orbitopathy (TAO) is an autoimmune inflammatory disorder that can affect the orbital and periorbital tissue, the thyroid gland and rarely the pretibial skin or digits.
- 4. Epidemiology TAO • Commonly presents during fourth and fifth decades • Median age at the time of diagnosis 43years • Range 8-88years
- 5. Epidemiology of TAO cont... 86% Women 14% Men TAO affects women approximately 6 times more frequently than men. Smokers are up to 7 times more likely than nonsmokers to develop TED. 89% Smokers 11% Nonsmokers
- 6. Etiology • TAO typically associated with Graves’ hyperthyroidism but may also occur with Hashimoto’s thyroiditis or in absence of thyroid dysfunction
- 7. Pathogenesis CD1 54 Orbital fibrobla st T cell Up-regulation – 1. IL-6 2. IL-8 3. PGE2 Synthesis of- Hyaluronan GAG is increased Derived from neural crest and possess developmental plasticity 1 A subpopulation undergoing adipocyte differentiation causing fatty hypertrophy particularly in those younger than 40 2 Up-regulation of TSH-R mRNA synthesis Adipogenesis- Expansion of orbital fat compartment 3 Circulating IgG activates insulin like growth factor Found in a majority with Graves disease 4
- 8. Histopathology Findings on histological examination- • Fibrosis with degenerative changes in the eye muscles • Lymphocytic cell infiltration • Enlargement of fibroblasts • Accumulation of mucopolysaccharides • Interstitial edema • Increased collagen production
- 9. Grossly Enlarge extraocular muscles in TAO
- 10. Clinical features of TAO
- 11. Eye signs of TAO
- 12. Dalrymple sign Von Graefe sign Kocher sign Goldzieher’s sign Courtesy by oculoplasty dept. of NIO&H
- 13. Mechanism of lid retraction •Fibrotic contracture of the levator •Secondary overaction of the levator superior rectus complex •Humorally induced overaction of muller muscles Courtesy by oculoplasty dept. of NIO&H
- 14. Proptosis • Axial • Uni/bilateral • Symmetrical/ asymmetrical Severe proptosis leads to - •Exposure keratopathy •Corneal ulcer •Infection Courtesy by oculoplasty dept. of NIO&H
- 15. Restrictive myopathy • Initially by inflammatory edema later for fibrosis •Elevation defect •Abduction defect •Depression defect •Adduction defect Courtesy by oculoplasty dept. of NIO&H
- 16. Optic neuropathy • Uncommon but serious complication • Caused by compression of the optic nerve or its blood supply at the orbital apex
- 17. Stages TAO •Congestive •Static •Fibrotic/quiescent Courtesy by oculoplasty dept. of NIO&H
- 18. NOSPECS classification of TAO
- 21. Investigation Thyroid function test- Others USG of thyroid gland Thyroid scanning FNAC Thyroid scintigraphy ECG Echocardiography •Serum free T3,T4,TSH •Thyroid stimulating immunoglobulin (TSI) •Thyroid binding inhibitory Ig •CT scan of orbit and brain
- 23. Courtesy by oculoplasty dept. of NIO&H •Fusiform enlargement of muscle •Tendon spearing •Muscle border smooth On CT scan of orbit and brain- Investigation cont…
- 24. Diagnostic criteria The diagnosis of TAO is made when 2 of the following 3 signs of the disease are present: 1. Concurrent or recently treated immune-related thyroid dysfunction (l or more of the following): a. Graves hyperthyroidism b. Hashimoto thyroiditis c. Presence of circulating thyroid antibodies without a coexisting dysthyroid state (partial consideration given): TSH-receptor (TSH-R) antibodies, thyroid-binding inhibitory immunoglobulins (TBll), thyroid-stimulating immuno-globulins (TSI), antimicrosomal antibody.
- 25. The diagnosis of TAO is made when 2 of the following 3 signs of the disease are present: 2. Typical orbital signs (l or more of the following): a. Unilateral or bilateral eyelid retraction with typical temporal flare (with or without lagophthalmos) b. Unilateral or bilateral proptosis (as evidenced by comparison with patient's old photos) c. Restrictive strabismus in a typical pattern d. Compressive optic neuropathy e. Fluctuating eyelid edema/erythema f. Chemosis/caruncular edema Diagnostic criteria cont…
- 26. The diagnosis of TAO is made when 2 of the following 3 signs of the disease are present : If only orbital signs are present the patient should continue to be observed for other orbital diseases and for the future development of a dysthyroid state 3. Radiographic evidence of TAO- unilateral/bilateral fusiform enlargement of 1 or more of the following : a. Inferior rectus muscle b. Medial rectus muscle c. Superior rectus/levator complex d. Lateral rectus muscle Diagnostic criteria cont…
- 27. Treatment of TAO Supportive measures Medical management Orbital radiation therapy Surgical management
- 28. Treatment of TAO cont… 1. Smoking cessation 2. Lubricating eye drops 3. Cool compression 4. Salt restriction 5. Elevation of head 6. Wearing sunglass
- 29. Treatment of TAO cont… 1. Systemic corticosteroids •Starting dose 60-100 mg orally •Short-term pulse intravenous dose 1gm daily several times a weak for up to 2 months 2. Others • Cyclosporine • Ticlopidine • Intravenous immune globulin • Somatostatin analogues
- 30. Treatment of TAO cont… • Orbital irradiation is prescribed for moderate to severe inflammatory symptoms, diplopia and visual loss in patients with TAO • Typical dose 2000 rad to each orbit, delivered as 200 rad/day for 10 days
- 31. Treatment of TAO cont… 1. Orbital decompression 2. Strabismus surgery 3. Eyelid surgery
- 32. Treatment of TAO cont… • Observation • Patient education/lifestyle changes • Smoking cessation • Salt restriction • Elevation of head of bed • Wearing sunglasses • Ocular surface lubrication • Topical cyclosporine • Eyelid taping at night • Moisture goggles/chambers • Prism glasses or selective ocular patching • Moderate-dose oral steroid therapy • High-dose oral steroid therapy • Intravenous steroid therapy • Surgical orbital decompression • Strabismus surgery • Eyelid surgery • Periocular radiotherapy Refractory disease • Steroid-sparing immunomodulators (rituximab) Mild diseas e Moder ate diseaseSevere disease
- 33. Prognosis • TAO is a self-limiting disease • On average lasts 1 year in nonsmokers and between 2 and 3 years in smokers • After the active disease plateaus, a quiescent burnt-out phase ensues • Reactivation of inflammation occurs in approximately 5%- 10% of patients over their lifetime Poor prognostic features- • Smoking • Rapidly progressive (typically congestive) TAO • Presence of myxoedema
- 34. THANK YOU & THANK TO THEM