Thyroid case presentation

Case Presentation

Presenter: Ravi Shankar Chaudhary

Moderator- Yashwant Goud

• MR No. P665641

• 40 year old

• Male

• Resident of Maharashtra

• Born of a non-consanguineous marriage

• Presented on March 21, 2012

Patient data

• Outward Protrusion of eyeball OU (OS > OD)

since 2 year.

• Diplopia OU since 15 days

• Redness OU since 2 months

• Sometimes mild pain OU

Chief complaints

• No h/o previous ocular disease or surgery and

using glasses.

• H/o hyper thyroidism since September 2010

• No h/o HTN,DM, and ocular allergy

Past history

• Tab methimazole 5mg since 1-2 years

Current medication

March 21, 2014 OD OS

Distance VA

(Unaided)

20/30 20/20

VA (PH) 20/20 20/20

Near(Unaided) N8 @30 cm with EC N8 @30 cm with EC

Flash Retinoscopy ±/- 0.75x90 Plano

Acceptance ±/-0.5x90(20/20) Plano(20/20)

Near(+1.0) N6 @30 cm with EC N6 @30 cm with

EC

IOP 12mmHg@1.30 pm 12mmHg @1.30pm

Ocular examination

February 26, 2014 OD OS

EOM Elevation +

depression

restriction

Elevation +

depression

restriction

Lids UL+LL retraction UL+LLretraction

Conjunctiva Congestion with

dilated episcleral

vessels

Congestion with

dilated

episcleral

vessels

Ocular examination

lid

retraction

February 26, 2014 OD OS

PFH 17mm 19mm

MRD 05mm 06mm

Hertel’s(100 ) 24mm 26mm

Scleral show

(inferiorly+superiorly)

03mm + 04 mm 04mm + 04 mm

Lagophthalmos 01mm 03mm

Colour vision WNL WNL

Schimer’s 1 32mm 17mm

Fundus OU Retina

attached

C:D 0.3:1 ,HNRR

No e/o disc

edema /pallor

C:D 0.3:1

,HNRR

No e/o disc

edema /pallor

PFHMRD1

Laophthalmos

Function and application of the hertel mirror

exophthalmometer

Differential diagnosis

• VEIIN +miscellaneous

– Vascular

– Endocrine

– Infection

– Inflammation

– Neoplastic

– Miscellaneous

Diagnosis

Thyroid eye disease(active)

Plan of Management

1. CT-scan orbit

2. Plan orbital decompression(OS-OD)

3. LPS recession(OU)

Advice

1. Clinical photos

2. CT-scan orbit

3. Continue thyroid medication

4. Glasses

5. RTC 3/12

Follow up after 3/12

May 11, 2012 OD OS

Aided vision 20/20,N6(@30c

m)

20/20,N6(@30cm

)

Cornea Clear Clear

AC PACD>1/2CT PACD>1/2CT

Iris No NVI/PXF No NVI/PXF

Pupil R/R/R No RAPD R/R/R

Lens Clear Clear

Colour vision WNL WNL

Hertel’s(100) 24mm 26mm

CT-scan

1. OU axial proptosis

2. OU all EOMs grossely thickened mainly

superior rectus and inerior rectus

3. Increased fat spaces

4. No optic nerve compression seen.

Advice

1. Schedule OS 3 wall decompression under

general anesthesia

Post op day 1

May 11, 2012 OD OS

VA (unaided) 20/30-20/20 20/40

Cornea Clear Minimal

oedema

conjunctiva quiet Congestion

AC PACD>1/2CT Hazy/quiet

Pupil R/R/R R/R/R

Suture N/A Intact

Wound N/A Healthy

Advice

1. Admit today

2. OS Ciplox e/d BD

3. OS Betameth e/d (6-4-3-2-1)

4. Tab combiflam BD

5. Clean wound with 5% betadine BD

6. OS Toba e/d Q4H

7. Exocin e/o BD

8. Refresh tears e/d QiD

9. RTC tomorrow with CECC 2 OPD

May 12, 2012 OD OS

VA (unaided) 20/30-20/20 20/40-NI

Cornea Clear Minimal

oedema

conjunctiva quiet Congestion

AC PACD>1/2CT PACD >1/2

CT/Hazy view

Pupil R/R/R R/R/R

Suture N/A Intact

Wound N/A Healthy

Review # day 1

Review # 6 weeks

Sub :- Has came for right eye surgery as advised

June 28, 2012 OD OS

VA (with PGP) 20/20 20/20

Cornea Clear Minimal

oedema

conjunctiva quiet quiet

AC PACD>1/2CT PACD >1/2 CT

Pupil R/R/R R/R/R

Suture N/A Removed

Wound N/A Healed

June 28, 2013 OD OS

Aided vision 20/20(N6@30cm) 20/20(N6@30c

m)

Lid UL retraction with

lateral flare

UL retraction

with lateral flare

Cornea Clear Clear

Hertel’s(100) 24mm 19mm

Lagophthalmos 01mm Nil

Colour vision WNL WNL

EOM movements restriction

elevation and

depression

Mild restriction

elevation and

depression

Right eye decompression was performed after 1

weeks and advised same treatment as in the other

eye

After 1 months

September 04, 2013 OD OS

Aided vision 20/20(N6@30cm) 20/20(N6@30c

m)

Lid UL retraction with

lateral flare

UL retraction

with lateral flare

Cornea Clear Clear

Hertel’s(100) 18mm 19mm

Lagophthalmos Nil Nil

Colour vision WNL WNL

EOM movements Mild restriction

elevation and

Mild restriction

elevation and

1.Clinical photos

2. LPS recession as per patient wish

3. RTC SOS

Advice

Thyroid disorders

• Hyper thyroidism

• Hypo thyroidism

• Euthyroidism

Is the TED and Grave’s eye disease is same or

different

If eye Is involved with thyroid dysfunction then

it is termed as graves ophthalmopathy or

thyroid eye disease

Differential signs

Thyroid disorders Thyroid eye disease

1. Weight loss 1. Lid retraction

2. Low/high body temperature 2. Proptosis

3. Loss of hairs 3. Dryness

4. Tremor 4. Lagophthalmos

5. Conjunctival Congestion

Different signs

1. Dalrymple’s sign:- Widened palpebral fissure height

2. Von graefe’s sign:- Lid lag in primary gaze

3. Jelink’s sign:- Hyper pigmentation of lid

4. Rosenbach’s sign:- Tremor of the lid

5. Stellwag’s sign:- Rare blinking

6. Griffith’s sign/kocher’s sign:- Lid lag lower lid while looking upward

Thyroid Eye Disease

Active Inactive

TED is a unique autoimmune disease

Differentiating‘Active

from ‘Inactive’disease is the first step in the

management of TED

1

Clinical Activity Score

(Mourits et al)

1. Spontaneous retrobulbar pain

2. Pain on eye movement

3. Eyelid redness

4. Swelling: Eyelids

5. Conjunctival redness

6. Conjunctival Chemosis

7. Swelling: Caruncle

8. Worsening of Proptosis (3 mth)

9. Worsening of EOM

10. Worsening visual acuity (3 mth)

Clinical Activity Score

(Mourits et al)

1. Spontaneous retrobulbar pain

2. Pain on eye movement

3. Eyelid redness

4. Swelling: Eyelids

5. Conjunctival redness

6. Conjunctival Chemosis

7. Swelling: Caruncle

8. Worsening of Proptosis (3 mth)

9. Worsening of EOM

10. Worsening visual acuity (3 mth)

Clinical Activity Score

(Mourits et al)

1. Spontaneous retrobulbar pain

2. Pain on eye movement

3. Eyelid redness

4. Swelling: Eyelids

5. Conjunctival redness

6. Conjunctival Chemosis

7. Swelling: Caruncle

8. Worsening of Proptosis (3 mth)

9. Worsening of EOM

10. Worsening visual acuity (3 mth)

Clinical Activity Score

(Mourits et al)

1. Spontaneous retrobulbar pain

2. Pain on eye movement

3. Eyelid redness

4. Swelling: Eyelids

5. Conjunctival redness

6. Conjunctival Chemosis

7. Swelling: Caruncle

8. Worsening of Proptosis (3 mth)

9. Worsening of EOM

10. Worsening visual acuity (3 mth)

All ‘angry eyes’ in TED do not imply Active

phase

2

Pathogenesis

Routine Imaging is

NOT required for the diagnosis of TED

(and measurements do not provide any

additional information)

3

Imaging is required ONLY for

1.Suspected nerve compression

2.For surgical planning

3.When diagnosis is suspected

Investigations

• Vision

• Color vision

• Complete ocular examination (CAS)

• Exophthalmometry

• Pupil examination

• Schirmer’s test

Thyroid Eye Disease

1. Identifying Active Disease

2. Investigations

3. Management of Active Disease

4. Management of Stable Disease

Management of TED

• Mild disease: 90%*

• Explain Natural history

• Lubricants

• Sleep with head end raised

• Maintain Euthyroid State

* Perros P, Clin Endocrinol, 1995

Management of the Thyroid Gland

HYPER

• Anti-thyroid medications

• Radioactive Iodine

• Thyroid Surgery

HYPO

• Thyroxin

Which form of Therapy is associated with Eye Disease?

Compresive Optic Neuropathy

• Medical Management

• Surgical Management

The goal of medical treatment is to use

appropriate therapy until the patient reaches the

inactive stage

4

Thyroid Eye Disease

1. Identifying Active Disease

2. Investigations

3. Management of Active Disease

4. Management of Stable Disease

Surgical Paradigm

• Decompression

• Strabismus

• Eyelid Surgery

• Cosmesis

Surgical treatment is performed in the

inactive stage

5

Orbital Decompression

• Expansion of the orbital volume by

- Bony expansion

- Fat removal

Orbital Decompression

Message home

– Eyelid retraction is the most common feature of TED

– TED is the most common uni/bilateral proptosis, markedly asymmetric

– 90% hyper, but 6% euthyroid

– Severity is not parallel to serum level (TSH, T3, T4..), but the smoking indeed 7x

– Urgent care may be require for CON, severe proptosis cornea decompensation

– Surgery should be in order: Orbital decompression Strabismus eyelid correction

Acknowledgement

Dr milind naik for photography and

review literature

Mr yashwant and winston for

guidance

Rohit,krishna ,saikat and niranjan for

suggestions and animations

Whole plasty

group for

encouragement

L V Prasad Eye Institute

www.lvpei.org

Excellenc

e

Equity Efficiency

Thank you!