The Eye & General Medicine

Exophthalmos & thyroid eye diseaseA case report for a ‘Grand Round’

Good Hope Hospital, March 2003

David Kinshuck, Associate Specialist, Eye Clinic

Case: Thyroid eye disease (Graves)

• 46y female• 1998 (41y) thyrotoxicosis,

treated with antithyroid drugs• 1999 radioactive iodine (systemic steroids 2 months)

• 2001 exophthalmos, active, referred• 2003 stable, but expecting treatment• Unhappy with appearance• Sore gritty watery eyes

Appearance

Upper lid retraction

Lower lid retraction

Exophthalmos (proptosis)

Dry eyes

Soft tissue lid swelling

Symptoms

Sore eyes/dry eyes/watery

Appearance

Optic nerve damage

glaucoma

Pathology, basis

• Enlarged ocular muscles & soft tissues

• Glycoproteins accumulate inside cells, lipid accumulation, lymphocytes, fibrosis

• Pushes eye forward… exophthalmos

• Or presses on optic nerve (blindness)

• Eye movements reduced, squints

What is happening in the orbit

TSH receptors

orb ita l fa t/m uscle

ce ll (G raves d isease)

Receptors increase with smoking

Hypothroidism increases TSH

TSH receptors

Cell swells up with glcycoproteins

etc

What do we do in eye clinic

Have to identify if active, and how active, and try and predict prognosis with and without

1 year

activ ity

none sm oker, euthyro id

1 year

activ ity

activ ity increases TSH level

1 year

activ ity

activ ity trip les 20 cigs/day

What do we do in eye clinic

Note symptoms/appearance

Measure exophthalmos/TED group

What do we do in eye clinic

Note symptoms/appearance

Measure exophthalmos/TED group

Afferent pupillary defect

Test visual fields, colour vision, eye pressure, examine optic disc

What do we do in eye clinic

Note symptoms/appearance

Measure exophthalmos/TED group

Afferent pupillary defect

Test visual fields, colour vision, eye pressure, examine optic disc

CT scan..diagnosis, especially if unilateral

What do we do in eye clinic

Note symptoms/appearance

Measure exophthalmos/TED group

Afferent pupillary defect

Test visual fields, colour vision, eye pressure, examine optic disc

CT scan..diagnosis, especially if unilateral

Diagnose/treat ‘active’disease

& inactive disease..eg lid/squint surgery

Proposed Classification System to Assess Disease Activity in Thyroid Eye Disease. One point is given for each sign present.

PainPainful, oppressive feeling on or behind the globePain on attempted up, side, or down gazeRednessRedness of the eyelidsDiffuse redness of the conjunctivaSwellingChemosisOedema of the eyelid(s)Increase proptosis of 2 mm or more during a period between 1 and 3 monthsImpaired functionDecrease in visual acuity of 1 or more lines on the Snellen chart (using a pinhole) during a period between 1 and 3 monthsDecrease of eye movements in any direction equal to or more than 5 degrees during a period of time between 1 and 3 months

(From Mourits et al)

Signs of activity:

• Puffiness increasing• exophthalmos increasing• pain increasing• patient is reasonable judge• optic nerve compression/field loss• diplopia beginning• all this early on in disease, unusual after 1 year

Treatment in active phase

• If active AND sight threatened, or proptosis disfiguring, systemic steroids(or it is reasonably clear this is likely)

• If activity continues despite steroids, radiotherapy to orbits

• Can decompress orbit surgically as alternative• Soft tissue activity only, no proptosis, so no

steroids• Depends on ‘activity’ score

• Can be difficult to determine whether disease is active

• Best results are when (severe cases) are given steroids early

• Don’t really know which the ‘severe’ cases are early on

1 year

activ ity

Threshold for steroids

1 year

activ ity

Threshold for steroids

Thyroid eye disease activity score

Red=very active=proptosis/optic atrophy

black=intermediate=some proptosis

green=soft tissue changes that will resolve

1 year

activ ity

Threshold for steroids

1 year

activ ity

Threshold for steroids

1 year

activ ity

Threshold for steroids

At onset difficult to judge outcome………………….

Our patient• Stable appearance for 2 years• Smokes, best to stop (may not make much

difference at this stage)• Offered referral for cosmetic surgery• Lid surgery (insert ‘spacer’ material)• possibly orbit surgery, more complex/risky

Illustrates problems in medicine (life) generally

• Treatments get more effective, more is known, making tremendous progress

• powerful treatments, side effects, • often hard to decide at the time what to do• sub-specialty training helps, but patients will not

present to the expert initially• treatment windows:

leaving things late causes problems• hard data lacking: cannot be trained for all problems