thyroid eye disease

Question 1

risk factors of thyroid eye disease

Answer 1

• ♀ sex (♀:♂ 6:1).
• hLA-Dr3, hLA-B8, and the genes for CTLA4 and the thyroid-
stimulating hormone (TSh) receptor.
• Smoking.
• personal or family history of autoimmune thyroid disease.

Question 2

emergencies of thyroid eye disease

Answer 2

acute progressive optic neuropathy

exposure keratopathy

Question 3

what is acute progressive optic neuropathy

Answer 3

due to compression of the nerve by involved tissues (mainly muscles) or by proptosis-induced stretch.

Question 4

Treatment of acute progressive optic neuropathy

Answer 4

• Systemic immunosuppression: this may be oral corticosteroids (e.g. 1mg/kg 1×/d pO prednisolone) or ‘pulsed’ (e.g. 500mg–1g IVMp 1×/d for the first 3d). response rates for pO steroid 750%, and IV steroid 780%. Monitor response over 1–2wk.
• repeat doses of IVMp may be given. The total dose should not exceed 8g in one course of therapy to avoid the small risk (0.8%) of acute liver damage.
• If this fails, then urgent surgical decompression is required.

Question 5

what is exposure keratopathy

Answer 5

dry eyes may arise due to proptosis and lid retraction.

Question 6

treatment for exposure keratopathy

Answer 6

lubricants, taping/frost suture/tarsorraphy, acute

immunosuppression (e.g. systemic corticosteroids) ± orbital decompression, levator recession.

Question 7

symptoms of thyroid eye disease

Answer 7

the patient may be eu-, hypo- or hyperthyroid at -the time of presentation

• exophthalmos
• conjunctival oedema
• optic disc swelling
• ophthalmoplegia
• inability to close the eyelids may lead to sore, dry eyes. If severe and untreated patients can be at risk of exposure keratopathy

ocular irritation
ache (worse in mornings)
red eyes
pain on eye movement
cosmetic changes
diplopia
visual loss

Question 8

signs of thyroid eye disease

Answer 8

proptosis (exophthalmos)
lid retraction (upper > lower)
lid lag (on downgaze)
lagophthalmos
conjunctival and caruncular injection and/or chemosis, orbital fat prolapse, keratopathy (exposure/superior limbic/KCS), restrictive myopathy, optic neuropathy.

Question 9

classification of TED

Answer 9

Type 1 - predominant orbital fat expansion

Type 2 - predominantly extraocular muscle enlargement)

Question 10

Assessment of TED activity

Answer 10

Mourits system

PAIN
pain painful, oppressive feeling on or behind globe +1 pain on eye movement +1

REDNESS
eyelid redness +1 Conjunctival redness +1

SWELLING
Swelling Swelling of lids +1 Chemosis +1 Swelling of caruncle +1 Increasing proptosis (≥2mm in 1–3mo) +1

IMPAIRED FUNCTION
Decreasing eye movement (≥5° in 1–3mo) +1
Decreasing vision (≥1 line pinhole VA on Snellen +1 chart in 1–3mo)

Total /10

Question 11

treatment of thyroid eye disease

Answer 11

systemic corticosteroids, but ciclosporin, methotrexate, azathioprine

Question 12

someone with TED when do u refer them urgently

Answer 12

unexplained deterioration in vision

awareness of change in intensity or quality of colour vision in one or both eyes

history of eye suddenly ‘popping out’ (globe subluxation)

obvious corneal opacity

cornea still visible when the eyelids are closed

disc swelling