Good Hope Eye Dept
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Good Hope Hospital Eye Clinic

Thyroid Eye Disease, diagnosis & treatment...some notes David Kinshuck

TED assessment
  • 50% of Graves disease patients have clinical TED, (40% more shown with CT scan),
    • ~10% have severe eye problems.
    • Worse with age
    • worse after radioactive iodine
    • 20 x worse in smokers
    • worse if thyroid control poor.
    • worse if hypothyroidism or hyperthyroidism occurs
    • worse if anti-thyroid antibodies present
  • It is an organ specific autoimmune disease leading to inflammation in the orbit, glycoaminoglycans deposition in cells, and such cells swell up with water.
  • 10% male;  2% of all females develop TED, age 20-50y
  • in 20% TED precedes the thyroid problem itself...patients are euthyroid at presentation
  • AIHT (autoimmune hyperthyroidism)
  • TED occurs most often 2 years after AIHT, sometimes 20 years later
  • 40% of patients are thyrotoxic with weight/appetite changes
  • if only the eyes are affected (TED), 78% will have been thyrotoxic, 2% hypothyroid
  • hypothyroidism..easy diagnosis   TSH high, T4 low
  • subclinical  hypothyroidism..easy diagnosis   TSH high, T4 normal
  • when looking up, eye pressure elevates >4mm in TED
 

 


History
  • EUGOGO case record form        form itself
  • typically starts 1-2 years after thyroid disease starts, but could precede thyroid disease. May occur 20y after the thyroid disease starts.
  • need past ocular history
  • any history of myasthenia?
  • excellent review NEJM Bahn 2010
  • dry, gritty, photophobia, watering, double vision, pressure behind eyes.
 

 


Examination

Vision etc

Soft tissue

  • periorbital oedema
  • periorbital erythema
  • conjunctival injection
  • chemosis
  • inflammation of caruncle/plica
  • plica visible when eye closed? (severe)
  • prolapse of conjunctiva
  • keratinisation of conjunctiva
  • upper lid retraction
  • lid lag
  • lagophthalmos
  • Bells..reduced = inferior rectus involved
  • photos   photos
  • severe chemosis

Slit-lamp

  • cornea...epitheliopathy
  • precorneal tear film, ulcer, scar
  • IOP
  • IOP up gaze

dilate

  • optic disc swelling/atrophy
  • choroidal folds

EOM

Orthoptics

  • HESS, BSV

Investigate

Proptosis

Summary

  • upper eyelid retraction, oedema, erythema of lids/conjunctiva, proptosis
  • 3% severe: severe pain, inflammation, corneal ulceration, optic neuropathy.
  • 13% pretibial (or elsewhere) skin changes..small % of these thyroid acropachy (clubbing)

 


Purpose of assessment

The aim is to determine activity and urgency of treatment.

TED


inactive


active


function eg diplopia or congested orbit 


cosmetic


sight safe


sight at risk

 


Purpose of assessment

The aim is to determine activity and urgency of treatment.
TED


inactive


active


function eg diplopia or congested orbit 


cosmetic


sight safe


sight at risk

 


Hydraulic disease

Occasionally there may be no response to steroids...the actual disease is inactive

  • steroids are not efffective, the eye remains exophthalmic despite treatment
  • there is no actual inflammation or autoimmmune reaction taking place
  • the eye is not red
  • there is mechanical obstruction to venous drainage...this is termed 'hydraulic' disease
  • vision may be affected; there may be considerable exophthalmos or optic nerve compression.
  • surgical orbital decompression may be very helpful and very effective
  • muscles enlarge in older patients, fat swells in younger Anderson 89
 

 


Interpretation of blood tests etc
  • hypothyroidism..easy diagnosis   TSH high, T4 low
  • subclinical  hypothyroidism..TSH high, T4 normal (and no clinical features)
  • measure TRH-receptor antibodies:  thyrotrophin receptor antibody (TRH receptor) levels are related to diseae activity Gerding 2000.
 

 


Subclinical  hypothyroidism
  • treat if symptoms, family history, antibodies present, dyslipidaemia, patient's preference, osteoporosis
  • low TSH is bad for the heart...TSH level directly related to heart disease
 

 


Other factors linked to TED

environmental

  • stress
  • smoking
  • drugs (eg amiodarone)
  • infection
  • low iodine in diet

modulating factors

  • pregnancy
  • E2 contraception

 

genes

  • eg DR3 CTAL4

 


Treatment of thyroid condition itself
  • subtotal thyroidectomy is generally best
  • radioactive iodine...15% get TED
  • use steroid cover to protect eyes...30mg day 4 weeks, then 20 mg/day for 4 weeks
  • as above avoid hypo and hyperthyroidism by adjusting thyroxine levels
 

 


Treatment of TED
  • IV methylprednisolone in the acute stage if condition is severe enough to treat see see .
  • 1g day for 3 days each week for 2 weeks EUGOGO 2008
  • if this works...oral prednisolone and gradually reduce dose
  • if it does not work, decompression surgery.
  • radiotherapy is losing popularity...not as effective as steroids
  • radiotherapy is dangerous and must not be given in diabetes as it increases retinopathy
  • surgical decompression can be very helpful if there is a poor response to steroids
  • if oral steroids are used, they should not be used long term
  • Azothiaprim, cyclosporin, and somatostatin alone are not effective
  • very rare deaths with methyprednisolone (liver failure), but only if total dose >8g
  • new treatments are being tried...rituximab, TSH receptor antagonists
  • clinic organisation is important
  • Selenium can help NEJM 2011

 

active TED, and if condition severe enough to treat


IV methylprednisolone in the acute stage if condition is severe enough to treat
1g day for 3 days each week for 2 weeks


improved

oral steroids short term


poor response

decompression surgery

 


Severity of TED...is treatment needed?

Patients with severe disease will have many signs and many of these (eg exophthalmos, diplopia, optic atrophy) will remain even after the disease becomes inactive.

Patients will mild disease will have few if any residual signs when the condition settles.

Patients with moderate disease will have some signs after the active phase finishes.

The active period generally does not last longer than 2 years.

enlarge

 


IV methylprednisolone in the active phase

Doctors need to determine which patient is in which group, when the disease is active, and if the activity is enough to lead to significant problems when the activity settles.

Treatment is given in the active phase (red block opposite) in all of the severe cases, and most of the moderate cases, and few of the mild cases.

Treatment (IV methylprednisolone) is given as early as possible in the active phase, and repeated if the activity does not settle. Severe cases may still need surgical decompression in addition, even in the active phase.

Patients with mild disease may prefer no treatment...as the steroids themselves have side effects. But those with severe disease should nearly always be offered treatment, as well as stopping smoking and having their thyroid disease itself stabilised.

enlarge

 


After the active phase

After the active phase, residual signs can only be treated with surgery.

  • orbital decompression for exophthalmos
  • lid surgery
  • squint surgery for double vision (this needs to be stable for 6 months before surgery)
 

 


Source

Notes from 2007 MOS meeting & 2008 College meeting
TED = thyroid eye disease

 

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