際際滷

際際滷Share a Scribd company logo

THYROID EYE DISEASE

Download as PPT, PDF
G
gbanstha

This document discusses thyroid diseases and their ocular manifestations. It focuses on Graves' disease, which causes Graves' ophthalmopathy - an autoimmune inflammatory disorder affecting the eye area. Symptoms include eyelid retraction, swelling, redness, and bulging eyes. Risk factors include female sex, smoking, and preexisting thyroid conditions. The document outlines pathogenesis, clinical features classified by severity, diagnostic tests, and treatment options including medications, surgery, and radiation therapy.

1 of 23
Downloaded 45 times
Thyroid Diseases Ocular Manifestations JeevanShrestha Presented by: Jeevan Shrestha KMCTH
I have no conflict of interest or disclosure in relation to this presentation.
Thyroid Disorders Graves Disease Hashimoto's Thyroiditis Thyroid Carcinoma Primary Hyperthyroidism Neck Irradiation JeevanShrestha
Graves Ophthalmopathy Is an autoimmune inflammatory disorder affecting the orbit around the eye, characterized by upper eyelid retraction, lid lag, swelling, redness, conjunctivitis, and bulging eyes. Various Names: Thyroid Eye Disease(TED) Thyroid-associated Ophthalmopathy (TAO) Dysthyroid Ophthalmopathy Thyroid Orbitopathy Endocrine Ophthalmopathy
Sex: More common in female than male 4:1 Smoking Middle age Autoimmune thyroid disease HLA-DR3 and HLA-B8 TED associated with Hyperthyroidism(90%), Hypothyroidism(4%), Euthyroidism(6%) Risk factors
Onset 20% of TED is diagnosed same time as hyperthyroidism 60% of eye disease occur after 1 year of thyroid disease Only 30% of hyperthyroidism TED
Pathogenesis Inflammatory targets: Primary: Orbital fibroblast Secondary: Extraocular muscles Activated T-cells act and stimulate adipogenesis, fibroblast proliferation and glycosaminoglycan synthesis. Enlargement of extraocular muscles due to edema and infiltration Orbital soft tissue infiltrated with lymphocytes, macrophages and mast cells
Pathogenesis Autoimmune disorder(IgG mediated) Enlargement of Extraocular Muscles - By Increase in Glycosaminoglycans Cellular Infiltration of Interstitial Tissues - With lymohocytes, plasma cells and macrophages, mast cell - Fibrosis Proliferation of Orbital fat, Connective tissue and Lacrimal Gland - With retention of fluid and GAG
Graves Ophthalmopathy Axial CT Extraocular Muscle Enlargement (Fusiform Appearance)
Clinical Features LID SIGNS - Retraction of Upper Lids (Dalrymples Sign) in 90% - Lid Lag in 50% (von Graefes Sign) - Fullness of Eyelids(Enroths sign) - Difficulty in Eversion of Upper Lid (Giffords Sign) - Infrequent Blinking( Stellwags Sign)
Clinical Features Conjunctival Signs: - Deep Injection and Chemosis Pupillary Signs: - Unequal dilated pupils Occular Motility Defects: - - Mobiuss sign Exophthalmos (60%) Exposure Keratitis and ocular discomfort Optic Neuropathy
Classification - By American Thyroid Association(ATA) Class 0: N : No signs and symptoms Class 1: O : Only signs( Lid retraction with/without lid lag & proptosis) Class 2: S : Soft tissue involvement with signs in class-1 and symptoms like . Lacrimation,photophobia, lid or conjunctival swelling Class 3: P : Proptosis well established Class 4: E : Extraocular muscle movement limited and diplopia Class 5 : C : Corneal involvement( Exposure Keratitis) Class 6: S : Sight loss (Optic nerve involvement and visual field defects)
Rundles Curve a - Mild Opthalmopathy b Ocular discomfort . . & eyelid disfunction c- Active Diplopia d- Optic Nerve. dysfunction
Diagnosis Graves Ophthalmopathy: 10-20% Precede hyperthyroid 40% Concurrent 30% < 6 months after diagnosis 10-20% > 6 moths after Dx
Investigations Thyroid Function Tests: - Serum T3,T4,TSH Positional Tonometry: Ultrasonography: - Changes in extraocular muscles Computerised tonographic scanning: - Show proptosis, Muscle thickness, Optic Nerve thickening MRI(T2- weighed and STIR): Orthoptic workup:
Treatment A) Non- surgical Management: - Smoking Cessation - Head elevation at night & cold compressors in morning(Reduce periorbital edema) - Lubricating artificial tear drops - Eyelid taping - Guanethidine 5% eyedrop ( Decrease lid retraction) - Prisms - Systemic steroids - Radiotherapy - Combined therapy : ( Low dose steroids + Azathioprine + Irradiation)
Treatment (B) Surgical Management: i)Orbital Decompression: - Two wall Decompression (Orbital floor and medial wall removed) - Three wall Decompression (Floor, medial and lateral wall removed) - Four wall Decompression ( Three wall removal plus lateral half of roof and. . . large portion of sphenoid at apex) ii) Extraocular muscle surgery: - Always done after orbital decompression - To achieve binocular single vision in reading position
Treatment iii) Eyelid Surgery : - Mullerotomy - Levator recession/disinsertion - Scleral grafts - Recession of lower eyelid retractors - Blepheroplasty
THYROID EYE DISEASE
THYROID EYE DISEASE
Dalrymples sign: Lid retraction von Graefes sign: Upper lid lag on downward Gaze Kochers sign: Increased lid retraction with visual fixation
Ballets sign: Palsy of one or more extraocular muscles Sukers sign:Weakness of fixation on lateral gaze Cowens sign: Jerky papillary contraction to consensual light Knies sign: Unequal dilatation of the pupils Jeffreys sign: Absence of forehead wrinkling on upward gaze Griffiths sign: Lower lid lag on downward gaze Stellwags sign: Infrequent blinking Enroths sign: Puffy swelling of the lids Mobius sign:Weakness of convergence mobius
THANK YOU Marty Feldman Presented By : Jeevan Shrestha

More Related Content

THYROID EYE DISEASE

  • 2. I have no conflict of interest or disclosure in relation to this presentation.
  • 3. Thyroid Disorders Graves Disease Hashimoto's Thyroiditis Thyroid Carcinoma Primary Hyperthyroidism Neck Irradiation JeevanShrestha
  • 4. Graves Ophthalmopathy Is an autoimmune inflammatory disorder affecting the orbit around the eye, characterized by upper eyelid retraction, lid lag, swelling, redness, conjunctivitis, and bulging eyes. Various Names: Thyroid Eye Disease(TED) Thyroid-associated Ophthalmopathy (TAO) Dysthyroid Ophthalmopathy Thyroid Orbitopathy Endocrine Ophthalmopathy
  • 5. Sex: More common in female than male 4:1 Smoking Middle age Autoimmune thyroid disease HLA-DR3 and HLA-B8 TED associated with Hyperthyroidism(90%), Hypothyroidism(4%), Euthyroidism(6%) Risk factors
  • 6. Onset 20% of TED is diagnosed same time as hyperthyroidism 60% of eye disease occur after 1 year of thyroid disease Only 30% of hyperthyroidism TED
  • 7. Pathogenesis Inflammatory targets: Primary: Orbital fibroblast Secondary: Extraocular muscles Activated T-cells act and stimulate adipogenesis, fibroblast proliferation and glycosaminoglycan synthesis. Enlargement of extraocular muscles due to edema and infiltration Orbital soft tissue infiltrated with lymphocytes, macrophages and mast cells
  • 8. Pathogenesis Autoimmune disorder(IgG mediated) Enlargement of Extraocular Muscles - By Increase in Glycosaminoglycans Cellular Infiltration of Interstitial Tissues - With lymohocytes, plasma cells and macrophages, mast cell - Fibrosis Proliferation of Orbital fat, Connective tissue and Lacrimal Gland - With retention of fluid and GAG
  • 9. Graves Ophthalmopathy Axial CT Extraocular Muscle Enlargement (Fusiform Appearance)
  • 10. Clinical Features LID SIGNS - Retraction of Upper Lids (Dalrymples Sign) in 90% - Lid Lag in 50% (von Graefes Sign) - Fullness of Eyelids(Enroths sign) - Difficulty in Eversion of Upper Lid (Giffords Sign) - Infrequent Blinking( Stellwags Sign)
  • 11. Clinical Features Conjunctival Signs: - Deep Injection and Chemosis Pupillary Signs: - Unequal dilated pupils Occular Motility Defects: - - Mobiuss sign Exophthalmos (60%) Exposure Keratitis and ocular discomfort Optic Neuropathy
  • 12. Classification - By American Thyroid Association(ATA) Class 0: N : No signs and symptoms Class 1: O : Only signs( Lid retraction with/without lid lag & proptosis) Class 2: S : Soft tissue involvement with signs in class-1 and symptoms like . Lacrimation,photophobia, lid or conjunctival swelling Class 3: P : Proptosis well established Class 4: E : Extraocular muscle movement limited and diplopia Class 5 : C : Corneal involvement( Exposure Keratitis) Class 6: S : Sight loss (Optic nerve involvement and visual field defects)
  • 13. Rundles Curve a - Mild Opthalmopathy b Ocular discomfort . . & eyelid disfunction c- Active Diplopia d- Optic Nerve. dysfunction
  • 14. Diagnosis Graves Ophthalmopathy: 10-20% Precede hyperthyroid 40% Concurrent 30% < 6 months after diagnosis 10-20% > 6 moths after Dx
  • 15. Investigations Thyroid Function Tests: - Serum T3,T4,TSH Positional Tonometry: Ultrasonography: - Changes in extraocular muscles Computerised tonographic scanning: - Show proptosis, Muscle thickness, Optic Nerve thickening MRI(T2- weighed and STIR): Orthoptic workup:
  • 16. Treatment A) Non- surgical Management: - Smoking Cessation - Head elevation at night & cold compressors in morning(Reduce periorbital edema) - Lubricating artificial tear drops - Eyelid taping - Guanethidine 5% eyedrop ( Decrease lid retraction) - Prisms - Systemic steroids - Radiotherapy - Combined therapy : ( Low dose steroids + Azathioprine + Irradiation)
  • 17. Treatment (B) Surgical Management: i)Orbital Decompression: - Two wall Decompression (Orbital floor and medial wall removed) - Three wall Decompression (Floor, medial and lateral wall removed) - Four wall Decompression ( Three wall removal plus lateral half of roof and. . . large portion of sphenoid at apex) ii) Extraocular muscle surgery: - Always done after orbital decompression - To achieve binocular single vision in reading position
  • 18. Treatment iii) Eyelid Surgery : - Mullerotomy - Levator recession/disinsertion - Scleral grafts - Recession of lower eyelid retractors - Blepheroplasty
  • 21. Dalrymples sign: Lid retraction von Graefes sign: Upper lid lag on downward Gaze Kochers sign: Increased lid retraction with visual fixation
  • 22. Ballets sign: Palsy of one or more extraocular muscles Sukers sign:Weakness of fixation on lateral gaze Cowens sign: Jerky papillary contraction to consensual light Knies sign: Unequal dilatation of the pupils Jeffreys sign: Absence of forehead wrinkling on upward gaze Griffiths sign: Lower lid lag on downward gaze Stellwags sign: Infrequent blinking Enroths sign: Puffy swelling of the lids Mobius sign:Weakness of convergence mobius