This is a presentation related to thyroid eye disease for medical students and doctors. by RABIA FAROOQ, final year mbbs student at mohiuddin islamic medical college, mirpur, AJK

1. THYROID EYE DISEASE
GRAVE’S OPTHALMOPATHY

2. INTRODUCTION

3. INTRODUCTION--THYROID EYE
DISEASE
• Seen in 25 – 50% of graves disease.
• GRAVES DISEASE also known as BASEDOW’S
DISEASE is an autoimmune disorder that
usually presents in 3rd to 4th decade of life,
affects women more than men, characterized
by a triad of features:
• Hyperthyroidism
• Diffuse thyroid enlargement
• Opthalmopathy

4. INTRODUCTION -- TED
• Thyroid eye disease (TED) may occur in the
absence of clinical and biochemical evidence
of thyroid dysfunction.
• The occurrence of signs of graves disease in a
patient who is not clinically hyperthyroid is
referred to as euthyroid or ophthalmic graves
disease.
• Eye disease may be the first presenting sign of
graves disease.

5. ETIOLOGY

6. ==GENETIC FACTOR
ASSOCIATION:
-- HLA DR3, CTLA-4, PTPN22
( a T- cell regulatory gene).
==AUTOIMMUNE DISEASE
ASSOCIATION:
-- Myasthenia gravis,
addison disease.
==RADIOACTIVE THYROID:
Thyroid ablation with orally
ingested radioactive
iodine-131 may excerbate
thyroid associated
orbitopathy compared with
anti-thyroid drugs and
surgical ablation.

7. •STRONG
ASSOCIATION OF
THYROID EYE
DISEASE WITH
SMOKING

8. PATHOGENESIS

9. PATHOGENESIS
• This involves an organ specific autoimmune
reaction in which a humoral agent (IgG antibody)
produces the following changes:
• INFLAMMATION OF EXTRAOCULAR
MUSCLES
• INFLAMMATORY CELLULAR
INFILTRATION

10. PATHOGENESIS:
INFLAMMATION OF EXTRAOCULAR MUSCLES
• Pleomorphic cellular infiltration, increased secretion
of glycosaminoglycans,osmotic retention of water.
• Muscles become enlarge( 8 times their normal size,
may compress optic nerve).
• Subsequent degeneration of muscle fibers eventually
leads to fibrosis
• Restrictive myopathy and diplopia.

11. HISTOLOGICAL PICTURE SHOWING ROUND CELL
INFILTRATION OF EXTRA OCULAR MUSCLES IN
THYROID EYE DISEASE

12. PATHOGENESIS:
INFLAMMATORY CELLULAR INFILTRATION
Infiltration with lymphocytes,
plasma cells, macrophages &
mast cells of interstitial fluid,
orbital fat & lacrimal glands
Increase in volume of
orbital contents &
secondary elevation of
intraorbital pressure.
Accumulation of
glycosaminoglycans &
retention of fluid.
Secondary elevation
of intraorbital
pressure.

14. CLINICAL MANIFESTATION
5 main clinical manifestations of TED are:
1… SOFT TISSUE
INVOLVEMENT
(PERIORBITAL & LID SWELLING,
CONJUCTIVAL HYPEREMIA.
2...LID RETRACTION
3…PROPTOSIS
(PASSIVE OR MECHANICAL
PROTRUSION OF EYE BALL)
4…OPTIC NEUROPATHY
(SERIOUS COMPLICATION –
COMPRESSION OF OPTIC NERVE
MAY LEAD TO VISUAL
IMPAIREMENT)
5…RESTRICTIVE
MYOPATHY
(OCULAR MOTILTY IS REDUCED
INITIALLY BY INFLAMMATORY
EDEMA & LATER BY FIBROSIS)

15. SYMPTOMS
OCULAR SYMTOMS
SYSTEMIC SYMPTOMS
•
•
•
•
•
•
•
•
•
•
•
•
•
•
DRY EYES
BULGING EYES
DIPLOPIA
VISUAL LOSS
OCULAR PRESSURE OR PAIN
PHOTOPHOBIA
LACRIMATION
TACHYCARDIA
NERVOUSNESS
HEAT INTOLERANCE
INCRESE SWEATING
WEIGHT LOSS
IRRATIBILITY
SKELETAL MUSCLE
WEAKNESS

16. OCULAR SIGNS
• PROPTOSIS ( eyes protude
beyond orbit…unilateral or
bilateral)
• Exophthlmos (appearance
of protuding eyes)
• Conjuctival edema
• Corneal ulceration
• Visual impairement
• Visual field defects
• Papilloedema
• Loss of colour vision
• Opthlmoplegia
• Optic disc usually normal
•
•
•
•
•
•
•
•
•
VIGOUROUX SIGN( eyelid fullness)
DALRYMPLE SIGN( lid retraction in
primary gaze)
von GRAEFE SIGN( retarted descent
of upper lid at downward gaze
STELLWAG SIGN
( incomplete & infrequent blinking)
GROVE SIGN( resistance to pulling
down the retracted upper lid)
JOFFROY SIGN ( abscent creases in
forehead on sup. gaze)
MOBIUS SIGN( poor convergence)
BALLET SIGN ( restriction of one or
more extra ocular movements)
KOCHER SIGN ( staring & frightened
appearance of eyes)

17. SEVERE BILATERAL PROPTOSIS & LID
RETRACTION IN THYROID EYE DISEASE

18. PERIORBITAL SWELLING IN THYROID
EYE DISEASE

19. LEFT EYE SHOW LID RETRACTION
&MILD PROPTOSIS

20. von GRAEFE SIGN( RIGHT EYE)

21. KOCHER SIGN

22. RESTRICTED LEFT EYE ABDUCTION

23. SYSTEMIC SIGNS
• FAST/ IRREGULAR
PULSE
• WARM MOIST SKIN
• FINE TREMOR
• PALMER ERYTHEMA
• HAIR LOSS

24. DIFFERENTIAL
DIAGNOSIS

25. DIFFERENTIAL DIAGNOSIS
• ORBITAL CELLULITIS: Onset of proptosis is
earlier & patient has other evidence of
infection. (fever)
• IDIOPATHIC ORBITAL INFLAMMATORY
DISEASE: More painful than thyroid eye
disease.
• OTHER CAUSES OF THICKENED
MUSCLES: sarcoidosis, amyloid, acromegaly.

26. INVESTIGATIONS

27. INVESTIGATIONS
NON- SPECIFIC
SPECIFIC
• ROUTINE BLOOD PICTURE.
• HAEMOGLOBIN.
• WBC( total & differential
count.)
• ESR.
• BLOOD SUGAR.
• CHOLESTROL.
• URINE EXAMINATION.
*FOR HYPERTHYROIDISM:
== SERUM T3 & T4 LEVEL
==SERUM TSH LEVEL.
*FOR OCULAR MUSCLE
ENLARGEMENT:
==PLAIN X-RAY CALDWELL
VIEW(PA view)
==ORBITAL ULTRASOUND
==CT SCAN ORBIT ( AXIAL &
CORONAL VIEW)
==MRI

28. Axial CT scan showing enlarged extra
ocular muscles in thyroid eye disease

29. TREATMENT

30. GENERAL MANAGMENT
CONTROL OF OCULAR DISCOMFORT
=Artificial tears
=Topical lubricants
=Sunglasses
ADVISE THE PATIENT TO
=Avoid smoking as it worsens the prognosis
=Avoid dust
=Elevate head when sleeping to avoid periorbital
edema

31. MEDICAL MANAGMENT
CONTROL OF HYPERTHYROIDISM
• Iodine and antithyroid drugs
• Radioactive iodine
ORBITAL DECOMPRESSION
Systemic steroids:
• Oral prednisolone: 60-80mg/day (dose should
be tappered after reduction in symptoms)
• I/V methylprednisolone: 0.5g in 200ml isotonic
saline over 30 min(may be repeated after 48 hrs)

32. SURGICAL MANAGMENT
Surgical treatment when there is severe sight
threatening condition or for cosmetic purpose.
ORBITAL DECOMPRESSION:
(for advanced proptosis & optic nerve compression)
STRABISMUS SURGERY:
(to minimize diplopia)
LID LENTHENING SURGERY

33. OTHER MANAGEMENT OPTIONS
RADIOTHERAPY
FUTURE OPTIONS
• ORBITAL RADIOTHERAPY
CAN BE USED TO TREAT
OPHTHALMOPLEGIA BUT
HAS LITTLE EFFECT ON
PROPTOSIS.
• THE RADIATION(1500-2000
Cgy fractioned over 10 days)
IS USUALLY ADMINISTERED
VIA LATERAL FIELDS WITH
POSTERIOR ANGULATION
• ANTI-TNF α
ANTIBODIES(eg infliximab)