This document discusses thyroid diseases and their ocular manifestations. It focuses on Graves' disease, which causes Graves' ophthalmopathy - an autoimmune inflammatory disorder affecting the eye area. Symptoms include eyelid retraction, swelling, redness, and bulging eyes. Risk factors include female sex, smoking, and preexisting thyroid conditions. The document outlines pathogenesis, clinical features classified by severity, diagnostic tests, and treatment options including medications, surgery, and radiation therapy.

1. Thyroid Diseases
Ocular Manifestations
JeevanShrestha
Presented by: Jeevan Shrestha
KMCTH

2.  I have no conflict of interest or disclosure in relation to
this presentation.

3. Thyroid Disorders
 Grave’s Disease
 Hashimoto's Thyroiditis
 Thyroid Carcinoma
 Primary Hyperthyroidism
 Neck Irradiation
JeevanShrestha

4. Grave’s Ophthalmopathy
 Is an autoimmune inflammatory disorder affecting the orbit
around the eye, characterized by upper eyelid retraction, lid lag,
swelling, redness, conjunctivitis, and bulging eyes.
 Various Names:
 Thyroid Eye Disease(TED)
 Thyroid-associated Ophthalmopathy (TAO)
 Dysthyroid Ophthalmopathy
 Thyroid Orbitopathy
 Endocrine Ophthalmopathy

5.  Sex: More common in female than male 4:1
 Smoking
 Middle age
 Autoimmune thyroid disease
 HLA-DR3 and HLA-B8
 TED associated with Hyperthyroidism(90%), Hypothyroidism(4%),
Euthyroidism(6%)
Risk factors

6. Onset
 20% of TED is diagnosed same time as hyperthyroidism
 60% of eye disease occur after 1 year of thyroid disease
 Only 30% of hyperthyroidism  TED

7. Pathogenesis
 Inflammatory targets:
 Primary: Orbital fibroblast
 Secondary: Extraocular muscles
 Activated T-cells act and stimulate
adipogenesis, fibroblast proliferation
and glycosaminoglycan synthesis.
 Enlargement of extraocular muscles
due to edema and infiltration
 Orbital soft tissue infiltrated with
lymphocytes, macrophages and mast
cells

8. Pathogenesis
 Autoimmune disorder(IgG mediated)
 Enlargement of Extraocular Muscles
- By Increase in Glycosaminoglycans
 Cellular Infiltration of Interstitial Tissues
- With lymohocytes, plasma cells and macrophages, mast cell
- Fibrosis
 Proliferation of Orbital fat, Connective tissue and Lacrimal Gland
- With retention of fluid and GAG

9. Grave’s Ophthalmopathy
Axial CT
Extraocular Muscle Enlargement
(Fusiform Appearance)

10. Clinical Features
 LID SIGNS
- Retraction of Upper Lids
(Dalrymple’s Sign) in 90%
- Lid Lag in 50% (von Graefe’s Sign)
- Fullness of Eyelids(Enroth’s sign)
- Difficulty in Eversion of Upper Lid
(Gifford’s Sign)
- Infrequent Blinking( Stellwag’s Sign)

11. Clinical Features
 Conjunctival Signs:
- Deep Injection and Chemosis
 Pupillary Signs:
- Unequal dilated pupils
 Occular Motility Defects:
- - Mobius’s sign
 Exophthalmos (60%)
 Exposure Keratitis and ocular
discomfort
 Optic Neuropathy

12. Classification
- By American Thyroid Association(ATA)
 Class 0: N : No signs and symptoms
 Class 1: O : Only signs( Lid retraction with/without lid lag & proptosis)
 Class 2: S : Soft tissue involvement with signs in class-1 and symptoms like
. Lacrimation,photophobia, lid or conjunctival swelling
 Class 3: P : Proptosis well established
 Class 4: E : Extraocular muscle movement limited and diplopia
 Class 5 : C : Corneal involvement( Exposure Keratitis)
 Class 6: S : Sight loss (Optic nerve involvement and visual field defects)

13. Rundle’s Curve
a - Mild Opthalmopathy
b – Ocular
discomfort . . &
eyelid disfunction
c- Active Diplopia
d- Optic Nerve.
dysfunction

14. Diagnosis
 Grave’s Ophthalmopathy:
 10-20% Precede hyperthyroid
 40% Concurrent
 30% < 6 months after diagnosis
 10-20% > 6 moths after Dx

15. Investigations
 Thyroid Function Tests:
- Serum T3,T4,TSH
 Positional Tonometry:
 Ultrasonography:
- Changes in extraocular muscles
 Computerised tonographic scanning:
- Show proptosis, Muscle thickness, Optic Nerve thickening
 MRI(T2- weighed and STIR):
 Orthoptic workup:

16. Treatment
A) Non- surgical Management:
- Smoking Cessation
- Head elevation at night & cold compressors in morning(Reduce periorbital
edema)
- Lubricating artificial tear drops
- Eyelid taping
- Guanethidine 5% eyedrop ( Decrease lid retraction)
- Prisms
- Systemic steroids
- Radiotherapy
- Combined therapy : ( Low dose steroids + Azathioprine + Irradiation)

17. Treatment
(B) Surgical Management:
i)Orbital Decompression:
- Two wall Decompression (Orbital floor and medial wall removed)
- Three wall Decompression (Floor, medial and lateral wall removed)
- Four wall Decompression ( Three wall removal plus lateral half of roof and. .
. large portion of
sphenoid at apex)
ii) Extraocular muscle surgery:
- Always done after orbital decompression
- To achieve binocular single vision in reading position

18. Treatment
iii) Eyelid Surgery :
- Mullerotomy
- Levator recession/disinsertion
- Scleral grafts
- Recession of lower eyelid retractors
- Blepheroplasty

21.  Dalrymple’s sign: Lid retraction
 • von Graefe’s sign: Upper lid lag on downward
Gaze
 • Kocher’s sign: Increased lid retraction with visual fixation

22.  • Ballet’s sign: Palsy of one or more extraocular muscles
 • Suker’s sign:Weakness of fixation on lateral gaze
 • Cowen’s sign: Jerky papillary contraction to consensual light
 • Knies’ sign: Unequal dilatation of the pupils
 • Jeffrey’s sign: Absence of forehead wrinkling on upward gaze
 Griffith’s sign: Lower lid lag on downward gaze
 • Stellwag’s sign: Infrequent blinking
 • Enroth’s sign: Puffy swelling of the lids
 • Mobius’ sign:Weakness of convergence
mobius

23. THANK YOU
Marty
Feldman
Presented By :
Jeevan Shrestha