Ocular Manifestations of Thyroid Disease
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Transcript of Ocular Manifestations of Thyroid Disease
OCULAR OCULAR MANIFESTATIONS OF MANIFESTATIONS OF THYROID DISEASETHYROID DISEASE
Graves ophthalmopathyGraves ophthalmopathy Other names: thyroid eye disease, thyroid Other names: thyroid eye disease, thyroid
orbitopathyorbitopathy Autoimmune inflammatory disorder whose Autoimmune inflammatory disorder whose
underlying cause continues to be elucidatedunderlying cause continues to be elucidated Signs and symptoms may progress and abate Signs and symptoms may progress and abate
independently of other clinical featuresindependently of other clinical features Eye findings may occur even in the absence Eye findings may occur even in the absence
of objective evidence of thyroid dysfunction of objective evidence of thyroid dysfunction (euthyroid Graves disease)(euthyroid Graves disease)
Graves ophthalmopathyGraves ophthalmopathyo Ophthalmopathy may relate to Ophthalmopathy may relate to
antibodies that cross-react with TSH-antibodies that cross-react with TSH-R antigens expressed on orbital R antigens expressed on orbital fibroblastsfibroblasts
PATHOGENESIS:PATHOGENESIS:Theories:Theories:
Glycosaminoglycans expressed from Glycosaminoglycans expressed from fibroblasts causes secondary water fibroblasts causes secondary water retention and therefore, retrobulbar retention and therefore, retrobulbar swellingswelling
TSH-R as the antigenTSH-R as the antigen
Fusiform enlargement of extraocular Fusiform enlargement of extraocular muscles; sparing of tendons muscles; sparing of tendons
Little enlargement of extraocular muscles but Little enlargement of extraocular muscles but marked increased in the orbital fat may occur.marked increased in the orbital fat may occur.
Diagnostic criteria for Graves Diagnostic criteria for Graves ophthalmopathyophthalmopathy
Key points about Grave’s Key points about Grave’s disease:disease:
Most common cause of eyelid retractionMost common cause of eyelid retraction
Most common cause of bilateral or unilateral Most common cause of bilateral or unilateral proptosis.proptosis.
More common in womenMore common in women
Associated with hyperthyroidism in 90% of patients; Associated with hyperthyroidism in 90% of patients; 6% are euthyroid6% are euthyroid
Smoking is associated with increased risk and severity Smoking is associated with increased risk and severity of ophthalmopathy.of ophthalmopathy.
The course of ophthalmopathy does not necessarily The course of ophthalmopathy does not necessarily parallel the activity of the thyroid gland or the parallel the activity of the thyroid gland or the treatment of thyroid abnormalities.treatment of thyroid abnormalities.
Grave’s disease/Thyroid Grave’s disease/Thyroid OphthalmopathyOphthalmopathy
Clinical signsClinical signs Eyelid retraction- Eyelid retraction-
most common signmost common sign Lid lagLid lag ProptosisProptosis Restrictive Restrictive
extraocular extraocular myopathymyopathy
Optic neuropathyOptic neuropathy
Other clinical features:Other clinical features:Most frequent ocular symptom is Most frequent ocular symptom is
pain or discomfort (30%)- often the pain or discomfort (30%)- often the result of dry eyesresult of dry eyes
Diplopia- 17%Diplopia- 17%Lacrimation/photophobia- 15-20%Lacrimation/photophobia- 15-20%Blurring of vision- 7.5%Blurring of vision- 7.5%
Non-ocular clinical findings:Non-ocular clinical findings:
Thyroid dermopathy- 4%Thyroid dermopathy- 4%Thryroid acropachy-1%Thryroid acropachy-1%Myasthenia gravis- 1%Myasthenia gravis- 1%
A. Bilateral proptosis and upper eyelid A. Bilateral proptosis and upper eyelid retractionretraction
B. Marked chemosis, eyelid swelling and B. Marked chemosis, eyelid swelling and increased proptosisincreased proptosis
• Bilateral lid retraction • No associated proptosis
• Bilateral lid retraction • Bilateral proptosis
• Lid lag in downgaze • Unilateral lid retraction • Unilateral proptosis
Soft tissue involvementPeriorbital and lid swelling
Chemosis
Conjunctival hyperaemia
Superior limbic keratoconjunctivitis
Proptosis
Treatment options • Systemic steroids • Radiotherapy • Surgical decompression
• Occurs in about 60% • Uninfluenced by treatment of hyperthyroidism
Axial and permanent in about 70% May be associated with choroidal folds
Optic neuropathy• Occurs in about 6% • Early defective colour vision • Usually normal disc appearance
Caused by optic nerve compression at orbital apex by enlarged recti
Often occurs in absence of significant proptosis
• Occurs in about 40% • Due to fibrotic contracture
Restrictive myopathy
Elevation defect - most common Abduction defect - less common
Depression defect -uncommon Adduction defect - rare
Treatment:Treatment: Correction of thyroid function abnormality- Correction of thyroid function abnormality-
Anti-thyroid drugsAnti-thyroid drugs Radio active iodineRadio active iodine thyroidectomythyroidectomy
Orbital decompression- to treat optic Orbital decompression- to treat optic neuropathy, orbital congestion, advanced neuropathy, orbital congestion, advanced proptosisproptosis
Topical ocular lubricantsTopical ocular lubricants Corticosteroid treatmentCorticosteroid treatment Orbital radiotherapy- targets lymphocytes?Orbital radiotherapy- targets lymphocytes?
Treatment and Prognosis:Treatment and Prognosis:Self limiting, but….Self limiting, but…. may run an active course of may run an active course of
exacerbation and remissionsexacerbation and remissionsTherapy directed toward decreasing Therapy directed toward decreasing
orbital congestion and inflammation orbital congestion and inflammation or expanding the bony volumeor expanding the bony volume
Treatment and Prognosis:Treatment and Prognosis:Often improves with establishment of Often improves with establishment of
euthyroid state, but eye disease may euthyroid state, but eye disease may continue to progresscontinue to progress
Elective orbital decompression, Elective orbital decompression, strabismus surgery and eyelid strabismus surgery and eyelid retraction repair usually are not retraction repair usually are not considered until a ophthalmic signs considered until a ophthalmic signs have been stable for 6-9 months.have been stable for 6-9 months.