thyroid eye disease
DESCRIPTION
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, AJKTRANSCRIPT
![Page 1: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/1.jpg)
THYROID EYE DISEASE
GRAVE’S OPTHALMOPATHY
![Page 2: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/2.jpg)
INTRODUCTION
![Page 3: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/3.jpg)
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
=HYPERTHYROIDISM
=DIFFUSE THYROID ENLARGEMENT
=OPTHLMOPATHY
![Page 4: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/4.jpg)
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.
![Page 5: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/5.jpg)
ETIOLOGY
THYROID EYE DISEASE
![Page 6: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/6.jpg)
ETIOLOGY
==GENETIC FACTOR ASSOCIATION: -- HLA DR3, CTLA-4, PTPN22( a T- cell regulatory gene).
==RADIOACTIVE THYROID: Thyroid ablation with orally
ingested radioactive iodine-131 may excerbate
thyroid associated orbitopathy compared with anti-thyroid drugs and surgical ablation.
==AUTOIMMUNE DISEASE ASSOCIATION:
-- Myasthenia gravis, addison disease.
![Page 7: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/7.jpg)
•STRONG ASSOCIATION OF
THYROID EYE DISEASE WITH
SMOKING
![Page 8: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/8.jpg)
PATHOGENESIS
![Page 9: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/9.jpg)
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
![Page 10: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/10.jpg)
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.
![Page 11: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/11.jpg)
HISTOLOGICAL PICTURE SHOWING ROUND CELL INFILTRATION OF EXTRA OCULAR MUSCLES IN
THYROID EYE DISEASE
![Page 12: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/12.jpg)
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.
![Page 13: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/13.jpg)
CLINICAL MANIFESTATIONS
![Page 14: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/14.jpg)
CLINICAL MANIFESTATION5 main clinical manifestations of TED are:
1… SOFT TISSUE INVOLVEMENT
(PERIORBITAL & LID SWELLING, CONJUCTIVAL HYPEREMIA.
2...LID RETRACTION3…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)
![Page 15: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/15.jpg)
SYMPTOMS
OCULAR SYMTOMS• DRY EYES• BULGING EYES• DIPLOPIA• VISUAL LOSS• OCULAR PRESSURE OR PAIN• PHOTOPHOBIA• LACRIMATION
SYSTEMIC SYMPTOMS• TACHYCARDIA• NERVOUSNESS• HEAT INTOLERANCE• INCRESE SWEATING• WEIGHT LOSS• IRRATIBILITY• SKELETAL MUSCLE
WEAKNESS
![Page 16: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/16.jpg)
OCULAR SIGNS• 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)
• 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
![Page 17: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/17.jpg)
SEVERE BILATERAL PROPTOSIS & LID RETRACTION IN THYROID EYE DISEASE
![Page 18: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/18.jpg)
PERIORBITAL SWELLING IN THYROID EYE DISEASE
![Page 19: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/19.jpg)
LEFT EYE SHOW LID RETRACTION &MILD PROPTOSIS
![Page 20: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/20.jpg)
von GRAEFE SIGN( RIGHT EYE)
![Page 21: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/21.jpg)
KOCHER SIGN
![Page 22: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/22.jpg)
RESTRICTED LEFT EYE ABDUCTION
![Page 23: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/23.jpg)
SYSTEMIC SIGNS
• FAST/ IRREGULAR PULSE
• WARM MOIST SKIN• FINE TREMOR• PALMER ERYTHEMA• HAIR LOSS
![Page 24: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/24.jpg)
DIFFERENTIAL DIAGNOSIS
![Page 25: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/25.jpg)
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.
![Page 26: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/26.jpg)
INVESTIGATIONS
![Page 27: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/27.jpg)
INVESTIGATIONS
NON- SPECIFIC• ROUTINE BLOOD PICTURE.• HAEMOGLOBIN.• WBC( total & differential
count.)• ESR.• BLOOD SUGAR.• CHOLESTROL.• URINE EXAMINATION.
SPECIFIC *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
![Page 28: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/28.jpg)
Axial CT scan showing enlarged extra ocular muscles in thyroid eye disease
![Page 29: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/29.jpg)
TREATMENT
![Page 30: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/30.jpg)
GENERAL MANAGMENTCONTROL OF OCULAR DISCOMFORT=Artificial tears=Topical lubricants=SunglassesADVISE THE PATIENT TO=Avoid smoking as it worsens the prognosis=Avoid dust =Elevate head when sleeping to avoid periorbital edema
![Page 31: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/31.jpg)
MEDICAL MANAGMENTCONTROL OF HYPERTHYROIDISM• Iodine and antithyroid drugs• Radioactive iodineORBITAL DECOMPRESSIONSystemic 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)
![Page 32: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/32.jpg)
SURGICAL MANAGMENT
Surgical treatment when there is severe sightthreatening condition or for cosmetic purpose.ORBITAL DECOMPRESSION: (for advanced proptosis & optic nerve compression)
STRABISMUS SURGERY: (to minimize diplopia)
LID LENTHENING SURGERY
![Page 33: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/33.jpg)
OTHER MANAGEMENT OPTIONS
RADIOTHERAPY• 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
FUTURE OPTIONS• ANTI-TNF α ANTIBODIES(eg infliximab)
![Page 34: Thyroid eye disease](https://reader033.vdocuments.us/reader033/viewer/2022061117/5467ee38af7959650e8b6ecb/html5/thumbnails/34.jpg)