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212- S + OM > Graves opthamology > Flashcards

Graves opthamology Flashcards

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1
Q

where is the thyroid gland located

A

highly vascular endocrine gland

lower neck anterior to trachea between the sternocleidomastoid muscles

consists of densely packed follicles

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2
Q

what is the function of the thyroid gland

A

concentrates iodide to form thyroid hormones

thyroid hormones synthesised and stored in the follicles

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3
Q

what are hormones does the thyroid secreate

A

trh stimulates the release of tsh
tsh is secreted by the anterior pituitary and stimulates the secretion of t3 - try-idothyroine
tetra idothyroonine t4 (thyroxine)

t3 and t4 recreated into bloodstream
bound to plasma proteins
free from intracellular

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4
Q

what are the roles of thyroid hormones

A

growth and development

rate of growth and many tissues
maturation of cns and bones
regulation of synthesis and some respiratory enzymes

metabolic effects
regulation of basal metabolic rate
regulation of water and ion transport
regulation of calcium and phsophorus metabolism
regulation of nitrogen metabolism

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5
Q

what is hyperthyroidism

A

enlarged thyroid gland - goitre
abnormal heart rhythms- tachycardia
increased appetite but may have weight loss
hand tremors
fine brittle hair
hyperactivity
heat intolerance and increased perspiration - warm , moist skin
lighter or less frequent periods
irratability
anxiety
muscle weakness - upper arms and thighs

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6
Q

what are symptoms of hypothyroidism ( underachieve)

A

fatigue , exhaustion
feeling run down and sluggish
unexplained / excessive weight gain
dry coarse , itchy skin and hair
slow heart rate
feeling cold , especially in extremities
goitre
more frequent periods
difficulty concentrating - brain fog
hoarse voice
muscle cramps

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7
Q

how are thyroid abnormalities diagnosed

A

tsh (considered outside normal if lower than 0.3 or higher than 3.0

calculate free t4 index (10-20)

thyroid stimulating immonoglobin (tsi)

anti thyroid antibodies

serum t3 - 2.5- 5.3 pmd

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8
Q

hyperthyroidism management

A

drug therapy

radioactive iodine treatment

thyroidectomy

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9
Q

hyperthyroidism treatment

A

thinomines - interfere with thyroid hormone synthesis by blocking the build of iodine

most effective if the onset of disease within 1 year

steroids- oral prednisone - decreases secretion of thyroid hormones and peripheral conversion of t4 and t3 - used in severe cases

immunosuppresants ( azathioprine or rituximab)

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10
Q

how is radioactive iodine used in the treatment of ted

A

radioactive iodine - taken up by thyroid gland - normal cell division = disturbed

used in patients over 45 yrs of age or in Younger patients if other treatments are contraindicated

ocular symptoms have been found to worsen following this treatement

20% of patients become hypothyroid within 1 year of the treatment

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11
Q

what effect does radioactive iodine and prohlaytic corticosteroids have on GO wheen treating hyperthyroidism

A

prevents progression of go in patients with pre- existing eye disease
eye signs worsened 6 months in

15% after ri

2.7% after antithyroid drugs

none who had ri and prednisone

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12
Q

how is a thyroidectomy used to treat hyperthyroidism

A

removal of the thyroid gland
reduces hormone production
post op recurrence in 10-15% patients
post op hypothyroidism in 40% of patients
usually performed in younger patients

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13
Q

what is used in patients with hypothyroidism

A

oral thyroxine

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14
Q

what is graves disease

A

autoimmune disorder that causes hyperthyroidism - the immune system attacks the thyroid and causes it to make more thyroid hormone the body needs
3 patients

all with enlargement of the thyroid gland
all with palpations
1 with protusion of the eyes

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15
Q

what is graves orbitoptahy

A

auto immune disease
disease of the orbit affecting the orbital soft tissues
closely correlated to auto immune systemic thyroid disease
presence of circulating antibodies that bind and stimulate the thyroid hormone receptor (tsh) leading to hyperthyroidism and goitre

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16
Q

what are risk factors of graves orbitopathy

A

genetic

environmental- smoking , stress

immune factors

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17
Q

what are risk factors of graves orbitopathy

A

female - 86%
16/10 000 women
3/ 10 000 men

Age- women - 40- 50 years

men 50- 55 years

greater severity with age

smoking- may known risk factor

severity of eye signs and symptoms with increased tobacco consumption

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18
Q

what thyroid abnormalities are associated with graves orbitopathy

A

hyperthyroidism - 90%

hypothyroid - 3-5%

euthyroid- 5% - sensitivity of detection]

patients hyperthyroid without eye signs - 50- 60 % - 80- 90% have eom changes on ct imaging

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19
Q

what are symptoms of thyroid eye disease

A

most common is change in appearance and/or ocular irritation

dry eyes

epiphora

grittiness

diplopia

photophobia/ flashing lights

reduced vision/ colour vision

pain/ ache on extreme gaze

distress at changing apperance

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20
Q

what lid abnormalities are seen in thyroid eye disease

A

upper or lower lid retraction

palpebral appeture - measurement can be taken

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21
Q

how to measure lid retraction

A

position patients head
ask patient to fixate on target positioned at their eye level and in the distance

ask patient to relax as much as possible to record the minimum amount of retraction for that patient (I.e Mullers muscle as relaxed as possible)

observer holds vertical clear plastic ruler near to visual axis without touching patients eyelashes

observer should consistently use only one of their eyes near to visual axis without touching eyelashes

observer should consistently use only one of their eyes and on the same horizontal level as the patients eye

for patients with manifest strabismus the contralateral visual axis is occluded prior to measurement

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22
Q

what instrument is used to measure exophthalmos/ proptosis

A

hertel mirror exopthalmometer

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23
Q

what should be noted about exopthalmos

A

if its bilateral
asymmetric
unilateral
normal

amount depends on severity of disease and inflammation and the structure of anterior orbital septum

axial/ non axial

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24
Q

what relating to oedema is caused by ted

A

lid oedema / periorbital odema

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25
what relating to the conjuctiva can be caused by ted
inflamamation of caruncle chemises, conjuctiva redness and swelling
26
what is affected in the eyes by graves orbitopathy
extra ocular muscles orbit lids sight
27
what happens during the wet phase (active phase) to extraocular muscles
wet phase- active phase cellular infiltration with gags (glycosminoaglycans( and osmotic inhibition of water this leads to eom becoming up to 8- 10x enlarged may compress optic nerve leading to visual loss subsequent degeneration of muscle fibres leads to fibrosis resulting in restricted motility and diplopia this phase tends to settle within 3 years
28
what is the fibrotic phase
muscle fibres become distorted , contracted and damaged due to fibrosis eyes are white and quiet painless restrictive myopathy may be present
29
what details need to be noted/ assessed regarding eom
limitation reversal saccades cog wheel pursuit fatigue pain retraction bilateral involvment
30
what is the order of eoms involved in ted
inferior rectus medial rectus superior rectus, lateral rectus superior oblique and inferior oblique vertical , horizontal and torsional diplopia swelling of eom results in restriction : if ir affected then patient unable to elevate as eye becomes tethered down
31
what is graves orbitpoathy and how is diagnosed
go is an autoimmune condition diagnosed by blood tests along with clinical history and assesment MRI scans can aid diagnosis patients are usually hyperthyroid but can be hypothyroid or euthyroid management of thyroid levels is an important first step in treatmenr 3 phases multiple distinctive eye signs can result in painful eye movements diplopia or visual loss upgaze typically affected first
32
what signs need to be present for a patient to be diagnosed with ted
clinical orbital signs `(lid retraction/ proptosis/ optic neuropathy) laboratory tests (positive bloods for autoantibodies) typical orbital imaging finding = swollen eoms
33
what are the signs and symptoms seen in the mild and early stages of ted
symptoms include----- foreign body sensation dry ete - excessive tearing , conjunctival or eyelid redness and swelling blurred vision retro - orbital pain clinical signs include ------- mild soft tissue inflammation dilated conjunctival vasculature keratoconjuctivitis corneal staining
34
what signs and symptoms seen in the moderate stage
pulling sensation around the eye eyelid redness and swelling
34
what signs and symptoms seen in the moderate stage
pulling sensation around the eye eyelid redness and swelling eyelid retraction and bulging eyes swelling of eom s cheomosis eyelid oedema proptosis
35
what symptoms would you see in advanced ted
horizontal, vertical and torsional strabismus with double vision deteriorating blurred vision fading colour vision in one or both eyes decrease in va , visual field and colour vision signs of optic neuropathy progressive proptosis with eyelid retraction corneal ulceration inflammation og eom and scarring leading to strabismus and opthalmolplegia increased top
36
describe the summary of the orthoptic role
diagnosis assessment of visual function document effects of ocular muscles record disease progress establish when ocular signs stabilise explaining and information signposting eliminate symptoms / diplopia plan long term management
37
outline the orthoptic investigation
ct , visual function , note any app - most common , head elevation om and measure pa bsv tests (inc vpfr) pct + torsion (synoptophore or torsionometer) funicular field of fixation field of bsv lees screen / hess (not useful in bilateral cases) measure 9 position of gaze due to them having an incomitiant deviation
38
what parts of visual function would be assessed
visual acuity colour vision - 100 hue , d15 Ishihara is used for congenital conditions visual fields contrast sensitivity pupils - checks for optic nerve , damage which may occur if on compression
39
what are the clinical; signs of optic nerve compression
on compression = a ocular emergency reduced va reduced contrast sensitivity reduced colour viision visual field defect rapd- relative afferent pupillary defect optic disc exam - normal/ swelling/ pallor optic neuropathy - approx - 5 %
40
with an acute presentation of ted what could you differentially diagnose it with
carotid - cavernous fistula mystic pseduotumour ocular myosotis leukemia orbital myositis chronic progressive external opthalmalplegia idiopathic orbital inflmmatory disease lymphoprolferative disorders carticocavernous fistula myasthenia gravis (in elderly males with inactive disease)
41
what classifications are seen for the diagnosis
Werners classification mouritis cas eugogo
42
what is Werners classification of ted
stage 1 - no ocular signs - stage 7 - sight loss
43
how does the European group on graves orbitpopathy
combines clinical activity score with measures of severity 1- spontaneous retrobulbar pain 7- conjunctival odema
44
what are the surgical mangement options
surgical - sight saving , strabismus, lid
45
what are the aims of orthoptic management
perserve visual function keep patient comfortable and symptom free allow comfortable bsv in primary position and reading poistion where possible
46
what are the management options for ted
encourage use of ahp
47
what are the management options for orthoptic management
encourage use of ahp prisms - tempoary / incorporated occlusion - blendaderm / patch / frosted lens surgery BT
48
What needs input from a opthamologist- non urgent
non urgently - gritty sensation/ and or eyes sensitive to light progressive change in eye appearance pain in or behind the eyes diplopia eyelid retraction swelling / redness of eyelids or conductive restriction of eye movement tilting of head to avoid double vision
49
what urgently needs input from the opthamologist
sudden deterioration in vision problems with colour vision sudden onset proptosis failure of full eye closure corneal opacity abnormal disc possible described referral to eye/ casualty or optmetrist
50
what surgical interventions can be suggested
on compression - orbital surgery strabismuss / ocular realignment surgery lid surgery multidiscpilanory approach - may involve maxillary facial surgeons , strabismologist and orbital surgeons
51
what orbital changes are seen in ted
retrobulbar adipose tissue is increased in volume and may have lymphocytic infiltrate increased volume of orbital contents typically leads to exophthalmos
51
what orbital changes are seen in ted
retrobulbar adipose tissue is increased in volume and may have lymphocytic infiltrate increased volume of orbital contents typically leads to exophthalmos may lead to on compression / neuropathy
52
what are the treatment options for optic neuropathy
steroids radiation orbital decompression
53
what type of steroids are given for optic neuropathy
mechanisms - anti-inflammatory immune response - immunosuppressive decrease mucopolysaccharide production by orbital fibroblasts indications - acute inflammatory disease optic neuropathy - mid va loss recent onset following other treatments - pre/post decompression
54
what are the effects of steroids + azthioprine
another immunosuppressants allowing reduction of steroid if prolonged large doses - reduces side effects of steroids effects modest
55
what are the effects of radiation therapy
well tolerated no short term side affects reduces symptoms but not the course of disease referral to oncologist face mask to immobilise patient and allow accurate delivery of radiation planning with ct 2 weeks of treatment delivered daily
56
how does radiotherapy work
reduce the cells which cause inflammation so reduce swelling behind the eye it may take up to year to notice the full effect 10 radiotherapy treatments given over two weeks face mask to immbolise patient and allow accurate delivery of radiation risk of cataract risk of dry eyes
57
how is radiation therapy utilised in the treatment of ted
daily doses od radiation beams directed at the orbital area low dose of 26y x ten days destroys lymphocytes and fribroblasts reducing auto immune response first weeks often in conjunction with steroids increased chemises in the first week of treatment improvement after 2 weeks of treatment if no improvement in 1 month treatment unlikely to improve
58
in what type of patients is radiation therapy indicated
indicated in patients with severe acute soft tissue signs ( steroids initially as radiotherapy not intermediate) recent onset progressive proptosis acute opthalmoplegia acute vision loss where steroid treatment has failed
59
in what type of patients is radiation therapy contraindicated
contraindicated/ not effective in patients with chronic ted minimal or no inflammation proptosis without inflammatory changes longstanding restrictive myopathy or rapid progression of disease male patients / smokers age under 50 years
60
how does radiotherapy treatment effect the clinical activity score
patients with a score lower than a 4 see a 80% chance of improvement patients with a score higher than a 4 see a 36% chance of improvement 4= swelling of lid (erythema)
61
what is orbital decompression
an operation to remove bone from the walls of the orbit- the eye socket- in order to reduce the amount of protusion in the eye this can be done laterally transantral transfrontal ethmoidal maxillary
62
what are indications for orbital decompression
- sight threatening situations improve cosmesis (40%, Lyons and footman)
63
what type of orbital compressions willl be perfumed
lateral orbital wall (single) - moderate proptosis medial wall and medial half of the floor and lateral wall are removed (severe proptosis) patients with sight threatening orbitopathy orbital fat decompression alone - mild proptosis
64
what are some of the complications regrading orbital decompression
complications include - temporary lib numbness sinusitis orbital cellulitis meningitis lower lid entropic blindness 1/10000 asymmetric correction of proptosis apparent upper lid retraction epiphora diplopia
65
how is strabismus associated with ted
occurs in 15-51% with ted diplopia which impacts on work/ driving ability to function independlty vertical
66
what are indications for strabismus surgery
medical condition stable eye condition stable problematic diplopia uncomfortable head posture centralise/ and or enlarge field of bsv
67
what type of eom surgery can be performed
forced auction testing - pre, intra and post up recession of muscles , avoid resections free adhesions undercorrection adjustable sutures - allow fine tuning and adjustment of app inferior rectus dissected from attachments to lower lid inferior rectus recession medial rectus recession - preferably wait for 6 months of stability
68
how are the lids affected in ted
lids retraction (upper and lower lid) levator palpeerde superioris muscle fibre enlargement oedema - rarely affects function overaction of mullers muscle (sympathetic overaction) innervation to superior rectus and levator palpable superioris
69
what drugs can be given for lid retraction
guanethidine topical drops -alpha adrenergic blocking agent triamcinolone - oral anti- inflammatory - anti fibrotic effect
70
what procedures can be done for lid retraction
levator muscles procedures mullers muscles procedures combination of above aim to leave ptotic - gradually elevates lateral tatsoophary- not effective - not used - may prevent exopthalmos
71
what levator muscle procedures can be done
recession tetnotomy
72
what is Hendersons operation
lid retraction - weakening of mullers muscles
73
what can be done to help peri- orbital oedema
blepharoplasty- surgical correction of lid deformity mark out excessive skin excuse skin and obicularis remove fat
74
what are the complications of a belphorplasty
infection bleeding dry / irrated eyes difficulty closing eyelids
75
what can be done to protect the cornea
tape lids glasses with Side protection hypromellose steroids orbital decompression tarsorraphy
76
what is rituiximab used for
ritxumab is a drug which depletes B cells promoting antibody dependent cellular toxicity sustained resolution of optic neuropathy and inflammation was found - no improvement of proptosis and strabismus
77
what is tepezza used for
new medicine to treat go human monoclonal antibody approved for use in use in jan 2020 expensive -
78
what does tepezza do
reverses proptosis by reducing inflammation and preventing tissue expansion - reduces diplopia and strabismus and orbital soft tissue volume in patients chronic ted imaging studies show reduction in eom size possibly Better strabismus outcomes
79
what are the side effects of tepezza
only medication that reduces fat and muscle expansion within the orbit only medicine to possibly reduce on compression some patients remain non responders to treatment possible side effects - hearing los , hypergluceima and muscle spasm

212- S + OM (10 decks)

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