Case description and clinical manifestations of TED

1. Dr.Maithri
DNB
Ophthalmology
THYROID EYE DISEASE
- Case and Discussion

2. History
 Chief complaints:
67 year old male
Decreased vision for distance and near in BE
since many years
Prominence of BE since 2 years

3.  Decreased vision in BE is gradually progressive and
painless.
 Vision improved to an extent after cataract surgery in BE
which was done 3 years ago but has again decreased
over the past few months
 H/O prominence of BE which was insidious and
simultaneous in onset, gradually progressive over 2
years with increased progression in the past 2 months.
 Associated with redness and mild discomfort
 No H/o pain, diplopia
 H/o of loss of appetite and loss of weight since 1 year
 No h/o neck swelling, tremors, skin pigmentation,
palpitations.
 No h/o trauma, fever

4. Past history:
 H/o Cataract surgery in BE 3 years ago
 H/o thyroid disease since 2 years on oral
medications
 Not a k/c/o DM/HTN/Asthma/ cardiac disease
Family history: Nothing significant
Personal History:
 Known smoker since 40 years, 4-5 cigarettes per
day
 Not alcoholic

5. General examination
 67 year old male conscious, alert, well oriented to
time, place and person.
 PR: 92 bpm
 Temp: Afebrile to touch
 BP: 130/80 mmHg
 CVS: S1, S2 heard, no murmurs
 RS/ PA/ CNS: Normal
 No pretibial myxedema
 No clubbing

6. Ocular examination
Head posture – normal
Facial symmetry – symmetrical
BCVA- RE: 6/18, N6 with -0.50/-0.75 + +2.50
LE: 6/36, N12 with -0.50 + +2.50
IOP – RE: 19mmHg, LE: 15mmHg
EOM – Restriction of abduction in BE
BE - Axial proptosis

7.  Anterior segment BE - conjunctival congestion
and pigmentation +
 Cornea was clear, no evidence of keratopathy
 Pupils – reacting briskly
 PCIOL +
 Fundus – Normal in BE

8. Proptosis evaluation
Inspection-
 Staring gaze present
 Hirshberg’s – orthophoric
 Nafziger’s sign – positive in BE
 Bushy eyebrows
 Temporal flare + in BE
 Lid retraction –
RE – UL – 2 mm LE – UL – 1.5 mm
LL – 4 mm LL – 3 mm

10.  Lagophthalmos + (3 mm in BE)
 Good Bell’s phenomenon
 No variation of proptosis with posture and
valsalva
Palpation:
 Orbital margins intact
 Resistance to retropulsion was present

11.  Hertel’s Exophthalmometry:
Base at 108
RE- 30mm
LE – 30mm
 Colour vision : normal

12.  Visual fields 30-2: Not reliable due to fixation loss
 MRI orbit – Showed compression of optic nerve

13.  VISA score:
 V- yes
 I – 2/10
 S – 1/3
 A – severe
Bilateral Thyroid Eye Disease – severe but no active
inflammation

16. Thyroid Eye Disease
 Two stages:
1. Inflammatory/ Congestive stage
2. Quiscent/ Fibrotic stage

17. TED
SOFT
TISSUE
INVOLVEM
ENT
PROPTOS
IS
RESTRICT
IVE
MYOPATH
Y
OPTIC
NEUROPA
THY
LID
RETRACTI
ON

18. Soft tissue Involvement
 Symptoms – irritation, grittiness, photophobia, dull
ache
 Signs – Epibulbar hyperemia
Periorbital edema – more in morning
Superior limbic keratoconjunctivitis
 Goldzeihers sign – conjunctival congestion

19. Lid Retraction
Due to –
a. fibrotic contracture
b. secondary overaction of LPS-SR complex
c. humoral overaction of muller’s muscle
Earliest signs: Upper eye lid retraction and
temporal flare

20. LID SIGNS
Eponym Sign
KOCHERS Staring appearance
VIGOUROUX Eyelid fullness or puffiness
VON GRAEFES Upper lid lag on downgaze
DALRYMPLES Upper eyelid retraction
STELLWAG Infrequent blinking
GIFFORDS Difficulty in everting upper lid
ENROTH Edema of lower lid
GRIFFITH Lower lid lag on upgaze

21. Proptosis

22.  Axial
 Unilateral/ Bilateral
 Symmetrical/ Asymmetrical
 Compromises lid closure – exposure keratopathy

23. Restrictive Myopathy
 30 – 50%
 Initially due to inflammation, later fibrosis
 1st muscle – Inferior rectus – contracture leads
to elevation defect
 Abduction defect – fibrosis of MR
 Depression defect – fibrosis of SR
 Adduction defect – fibrosis of LR
 Moebius sign – unable to converge eyes

24. Ballets sign – restriction of 1 or
more EOM

25. Optic Neuropathy
 Compression of optic nerve at apex due to
enlarged muscles
 Decreased visual acuity – central vision
 Decreased colour intensity – sensitive indicator
 RAPD
 Visual fields – central or inferior altitudinal defects
 Optic disc – normal/ swollen/ atrophic
 Retina may show choroidal folds (sallmanns)

26. CT Scan – axial view, showing muscle
enlargement and compressing the optic nerve

27. Conclusion
 Thyroid eye disease is a consortium of signs each of
which have a diagnostic and prognostic value
 EOM restriction shouldn’t be confused with nerve
palsies, optic neuropathy should be differentiated
from glaucoma
 To make the patient aware of the disease and
potential complications is important
 Each of the 5 manifestations need to be dealt with
individually and as a whole keeping in mind the

28. Thank you