1. The Eye & General Medicine
Exophthalmos & thyroid eye disease
A case report for a ‘Grand Round’
Good Hope Hospital, March 2003
David Kinshuck, Associate Specialist, Eye Clinic

2. 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

3. 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

4. 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

5. What is happening in the orbit

6. TSH Hypothroidism
re c e p to rs increases TSH
o r b ita l
fa t/m u s c le
c e ll
(G ra v e s
d is e a s e )
Receptors
increase with
smoking

7. TSH
re c e p to rs
Cell swells up
with glcycoproteins
etc

8. What do we do in eye clinic
Have to identify if active, and how active, and
try and predict prognosis with and without

9. a c tiv ity
n o n e s m o k e r , e u th y r o id
1 year

10. a c tiv ity
a c tiv ity in c r e a s e s T S H le v e l
1 year

11. a c tiv ity
a c tiv ity tr ip le s 2 0 c ig s /d a y
1 year

12. What do we do in eye clinic
Note symptoms/appearance
Measure exophthalmos/TED group

13. 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

14. 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

15. 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

16. Proposed Classification System to Assess Disease Activity in
Thyroid Eye Disease. One point is given for each sign present.
Pain
Painful, oppressive feeling on or behind the globe
Pain on attempted up, side, or down gaze
Redness
Redness of the eyelids
Diffuse redness of the conjunctiva
Swelling
Chemosis
Oedema of the eyelid(s)
Increase proptosis of 2 mm or more during a period between 1 and 3
months
Impaired function
Decrease in visual acuity of 1 or more lines on the Snellen chart (using a
pinhole) during a period between 1 and 3 months
Decrease 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)

17. 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

18. 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

19. • 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
Threshold
for
a c tiv ity steroids
1 ye a r

20. Threshold
for
a c tiv ity steroids
Thyroid eye
1 year Red=very active=proptosis/optic atrophy
disease activity black=intermediate=some proptosis
score
green=soft tissue changes that will resolve

21. Threshold
for
a c tiv ity steroids
1 year

22. Threshold
for
a c tiv ity steroids
1 year

23. Threshold
for
a c tiv ity steroids
1 year
At onset difficult to judge outcome………………….

24. 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

25. 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