Thyroid Eye Disease/Thyroid Orbitopathy

Question 1

What is it?

Answer 1

Autoimmune, inflammation of orbital tissue in patients with thyroid disease.

Question 2

What causes this?

Answer 2

Stimulation of orbital fibroblasts that up regulate the synthesis of GAGs that deposit in orbital tissues leading to congestion and edema.

These fibroblasts can differentiate into adipocytes or my-fibroblasts that lead to fat accumulation and muscle enlargement.

Question 3

90% of TED are associated with

Answer 3

Graves disease. Also associated with Hyperthryoidism, hypothyroidism, and Hashimoto’s

Question 4

Demographics

Answer 4

Women 40-60 years

Question 5

Laterality

Answer 5

Bilateral

Question 6

Symptoms

Answer 6

Dry eye due to exposure (lagophthalmos) 
Elevation of upper lid, above limbus. 
Bulging eyes
Eyelid swelling 
Double vision 
Pain on eye movement

Question 7

Sign

Answer 7

Upper eyelid retraction (Dalrymple’s sign, lagophthalmos, or temporal flare)

Exophthalmos (proptosis, globe protrudes)

Periorbital edema and erythema

Conj injection and chemosis (at rectus muscle insertion)

Exposure keratopahy due to lagophthalmos and exophthalmos.

Superior limbic keratoconjunctivitis. Inflammation of the superior limbus (K, bulbar and tarsal conj)

Von Grafe’s sign (Dynamic)

Eyelid lag (static)

pain on EOMs

Question 8

3 signs that go along with upper eyelid retraction

Answer 8

1. Dalrymple’s sign. Widening of the palpebral fissure with superior scleral show.
2. Lagophthalmos. Inability to close the eyes completely.
3. Temporal flare. Elevation of the temporal upper eyelid to its normal anatomical location.

Question 9

Where will I likely see conj injection and chemosis

Answer 9

More pronounced at site of rectus muscle insertion

Question 10

Exposure keratopathy

Answer 10

Cornea damage that occurs from prolonged exposure to the outside environment. Due to lapopthalmos and exophthalmos.

Question 11

Superior limbic keratoconjunctivitis

Answer 11

Inflammation of the superior limbus, cornea, bulbar and tarsal conj

Question 12

Von Grafe’s sign

Answer 12

Delayed descent of the upper eyelid during downgaze. Dynamic finding.

Pt looks down- upper eyelid is slower.

Question 13

Eyelid lag

Answer 13

Upper eyelid is higher than normal when the eye is in downgaze. Static finding.

Question 14

What two recti muscles are most commonly affected? leading to __

Answer 14

inferior and medial. Leading to hypotropia and esotropia.

Question 15

Complications

Answer 15

Compression of the globe or ON.

Question 16

Compressive optic neuropathy occurs in __% of cases

Answer 16

5

** Why you should dilate to look at ON

Question 17

Management

Answer 17

Always dilate to look at ON
Topical lubrication
Dry eye tx 
Eyelid taping or patching qhs- sleep mask. 
Cold compress qam and head elevation qhs
sodium restriction 
prism for diplopia. 
**Smoking cessation.

Question 18

Smokers with graves disease are __x more likely to develop TED compared to nonsmokers.

Answer 18

7x. Must talk to them about stopping.

Question 19

How to manage moderate to severe cases of compressive optic neuropathy?

Answer 19

Oral or IV steroid.
Orbital radiotherapy.
Orbital decompression surgery.

Question 20

When to order orbital CT or MRI?

Answer 20

Severe congestive orbitopthaly or optic neuropathy or atypical cases. Unilateral proptosis or bilateral proptosis without upper eyelid retraction.

Question 21

Exophthalmometry

• What is it
• What are normal limits

Answer 21

Monitors exophthalmos.
12-20mm whites
12-24 mm blacks
Within 2 mm between the eyes

Question 22

What is the most common cause of orbital disease in adults?

Answer 22

TED

Question 23

What is the most common presenting sign of TED.

2nd most common?

Answer 23

Upper eyelid retraction is most common. 2nd most is exophthalmos.

Question 24

What causes upper eyelid retraction?

Answer 24

Increased sympathetic tone acting on muller’s muscle, contraction of the levator, proptosis and/or scarring between the levator and lacrimal gland.

Question 25

Divided into which two phases?

Answer 25

Active phase (progressive)

• Lasts 1-3 years.
• Symptoms wax and wane
• 5-10% risk of recurrence.

Stable phase.
-Spontaneous resolution of the active phase.

Question 26

What measuring system is used to classify severity

Answer 26

Wener’s NOSPECS

Class 0- no signs or symptoms
Class 6- Sight loss due to ON involvement

Question 27

When can surgery be advised?

Answer 27

Until the thyroid state is maintained and the TED has been in the stable phase for at least 6-9 months.

Exceptions include vision loss from compressive optic neuropathy or exposure keratopathy.

Question 28

What % of patients with TED undergo surgical intervention?

Answer 28

20%

Question 29

Does TED follow the associated thyroid disfunction?

Answer 29

No. may occur months-years before or after thyroid disfunction.

Question 30

What other disease may occur in a minority of patients?

Answer 30

Myasthenia Gravis.

Fluctuating diplopia and ptosis that is worse at the end of the day.