Thyroid Ophthalmopathy 2 Slide

8/17/2019 Thyroid Ophthalmopathy 2 Slide

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Grave’s Ophthalmopathy (GO)

Clinical presentation

&

Medical treatment

Parima Hirunwiwatkul, MD

Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University

Clinical presentation

• Dryness and irritation

• Inflammation and pain

• Visual disturbance

– Afferent: Decrease acuity, dimming, scotoma,

color change

–

• Cosmetic


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Eye involvement in GO

Class 0 • No symptoms or signs

Class I • Only signs, no symptoms (lid retraction, stare, lid lag)

Class II • Soft tissue involvement

Class III • Proptosis

• Extraocular muscle involvement

Class V

• Corneal involvement

Class VI • Sight loss (optic nerve involvement)

Treatment of TRO

• Avoid risk factors

• ymp oma c rea men

– Lubricant

– Anti‐inflammation : steroids

• Medical treatment

– Systemic steroids

– Immunosuppressive

– Botulinum toxin

• Surgical treatment


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Lubricants

• Artificial tears:

– Preservative artificial tear

– Disappeared preservative

– Non preservative/ preservative free

• Form:

– – ,

– Eye gel

No symptoms or signs

• NoneSymptoms:

• NoneSigns:

• NoneTreatment:


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Only signs, no symptoms

• unequal eye Symptoms:

• Lid retraction, stare, lid lagSigns:

• Control thyroid hormone condition

• Botulinum toxin injected to Muller muscle

Treatment:

Soft tissue involvement

• Pain, irritation, redness,

• Deep conjunctival injection, especially over the rectus muscle insertions.

• Conjunctival chemosis

• Edema of the caruncle

• Inflammation may result in periorbital

cosmetic

Signs:

edema and erythema.

• Avoid risk, sleep position

• Lubricants

• Topical steroids (+ oral)Treatment:


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Proptosis

• Extruded eyeball from globe

• Dryness

• Proptosis

• Lagophthalmos

• Corneal exposure

Signs:

• Avoid risk, sleep position

• Lubricants• Tarsorrhaphy : medical/surgical

Treatment:

Extraocular muscle involvement

• Double vision

• Cannot move the eyes

• Misalignment of globe

• Limitation of eye movement by EOM involvement

Signs:

• Symptomatic: Patching, prism, Botulinum

toxin injected to Rectus muscle

• Systemic steroids

Treatment:


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Corneal involvement

• Dryness, pain, redness S m toms:

• ecrease v s on

• Conjuntival injection

• Corneal ulceration/ perforationSigns:

• u r can s, op ca an o cs

• Tarsorrhaphy : medical/surgical

• Corneal surface reconstruction: AMT, corneal transplantation

Treatment:

Sight loss

• Decreased visionS m toms:

• ↓ optic nerve function: color, brightness, contrast, VF

• RAPD ‐positive

• + Disc swelling/atrophy

Signs:

• Medical/surgical decompression: systemic/local steroids injection, Botulinum toxin injection, OR, surgery

Treatment:


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*This paper is also being published in the March 2008 issue of the journal,

European Journal of Endocrinology, vol. 158, no. 3.

Recommendations

Referral to combined thyroid‐

eye clinics and Smoking and GO

Management of hyperthyroidism in patients with

initial assessment GO

Other simple measures that may alleviate

symptoms

Grading severity and activity of GO

Management of sight‐threatening

GO

Management of moderate to

severe GO

Management of mild GO

Special situations


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should be addressed by

both nonspecialists and specialists

Referral to combined thyroid ‐eye clinics

and initial assessment

Should all patients with GO be referred to

Primary care physicians, general practitioners, general internists and specialists, who have no

com ne yro –eye c n cs

particular expertise in managing GO, should refer patients with GO, except for the mildest cases, to combined thyroid‐eye clinics for

further assessment and management


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Refer urgently

• Symptoms

–

– Awareness of change in intensity or quality of colourvision in one or both eyes

– History of eye(s) suddenly ‘popping out’ (Globe subluxation)

• Signs

– Obvious corneal opacity

– Cornea still visible when the eyelids are closed

– Disc swelling

Refer urgently

• Compressive optic neuropathy (Dysthyroid

op c neuropa y

• Exposure keratopathy … corneal melting

…corneal perforation


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Refer non‐urgently

• Symptoms – Eyes abnormally sensitive to light: troublesome or deteriorating over

the past 1–2 months

– lubricants

– Pain in or behind the eyes: troublesome or deteriorating over the past 1–2 months

– Progressive change in appearance of the eyes and/or eyelids over the past 1–2 months

– Appearance of the eyes has changed causing concern to the patient

– Seeing two separate images when there should only be one

gns – Troublesome eyelid retraction

– Abnormal swelling or redness of eyelid(s) or conjunctiva

– Restriction of eye movements or manifest strabismus

– Tilting of the head to avoid double vision

Smoking and

GO

Is smoking related to the occurrence,

All patients with Graves’ disease should be informed of the risks of smoking for GO emphasizing the detrimental effects of smoking on:

‐development of GO (IIb, B)

sever y, an progress on o

‐deterioration of pre‐existing GO (IIb, B)

‐effectiveness of treatments for GO (IIb, B)

‐progression of GO after radioiodine treatment (Ib, A)

If advice alone is ineffective, referral to smoking cessation clinics, or other smoking cessation strategies should be considered (IV, C)


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Management of hyperthyroidism in

patients with GO

1. Is correction of thyroid dysfunction

• Euthyroidism should be restored promptly and maintained

important for GO?

s a y n a pa en s w ,

• Frequent monitoring of thyroid status (every 4‐6 weeks) is imperative in the initial phases of treatment when changes in

thyroid status are expected (IV, C)

Management of hyperthyroidism in

patients with GO

2. Is there a relationship between modality of

• Patients with active GO given radioiodine should be offered prophylactic steroid cover (commencing with 0.3‐0.5 mg of prednisone/kg /day orally 1‐3

days after radioiodine and tapering the dose until withdrawal about 3

treatment or ypert yroi ism an t e course o GO

mont s ater I , A• Shorter periods of glucocorticoid therapy (1‐2 months) may be equally

protective (IV, C)

• Patients with inactive GO can safely receive radioiodine without steroid cover, as long as hypothyroidism is avoided (IIb, B), particularly if other risk

factors for GO progression, such as smoking, are absent (IV, C)


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Other simple measures

that may alleviate symptoms

Are there worthwhile simple measures that can

• Lubricant eye drops during the day and/or lubricant ointments at night‐time are recommended for all patients with GO who have

symptoms of corneal exposure (III, B)

• Patients with symptomatic diplopia should be given prisms if appropriate (IV, C).

• Botulinum toxin injection may be considered for upper lid retraction in centres who have experience and expertise in this

technique (IV, C).

should be addressed

in specialists centers


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Activity measures

based

on

features

of

inflammation:

clinical activity score (CAS)

Spontaneous retrobulbar pain

Pain on attempted up‐ or down gaze

Redness of the eyelids

Redness of the conjunctiva

Swelling of the eyelids

Inflammation of the caruncle and/or plicaConjunctival oedema

A CAS (sum of all items present) > 3/7 indicates active GO

Severity measures• Lid aperture

– distance between the lid margins in mm with the patient looking in the primary position, sitting relaxed and with distant fixation

• Swelling of the eyelids

•

• Redness of the conjunctiva

• Conjunctival oedema

• Inflammation of the caruncle or plica

• Exophthalmos – using the same Hertel exophthalmometer

• Subjective diplopia score – , ,

• Eye muscle involvement – ductions in degrees

• Corneal involvement (absent/punctate keratopathy/ulcer)

• Optic nerve involvement – best corrected visual acuity, color vision, optic disc, RAPD (absent/present), plus visual fields if

optic nerve compression is suspected


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Severity classifications

in

GO

1. Sight‐threatening GO:

atients with d sth roid o tic neuro ath DON and/or corneal breakdown.

This category warrants immediate intervention.

Grading

severity

and

activity

of

GO

Severity classifications in GO

2. Moderate to severe GO:

No sight‐threatening GO

Usually have any one or more of the following:

lid retraction > 2mm, moderate or severe soft tissue ,

gender, inconstant or constant diplopia.

Eye disease has sufficient impact on daily life to justify the risks of immunosuppression (if active) or surgical intervention (if inactive).


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Severity classifications

in

GO

3. Mild GO:

Only a minor impact on daily life insufficient to justify immunosuppressive or surgical treatment.

T ey usua y on y ave one or more o t e following: minor lid retraction (


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Management of mild GO

Is a ‘‘wait and see’’ strate reasonable?

Watchful waiting is appropriate for the

majority of patients with mild GO (IV, C).

Management of

mild

GO

How should mild eyelid retraction, soft tissue swelling,

the orbital disease?

In a minority of patients with mild disease, quality of life may be so profoundly affected as to justify using

treatments as for moderate to severe disease (IV, C).


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Early detection and referral to

ophthalmologist

Documents

Thyroid Ophthalmopathy 2 Slide