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
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
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
