Slide 1: 1 THYRIOD EYE DISEASE Dr. Gyanendra Lamichhane
Lumbini Eye Institute
Bhairahawa ,Nepal References : 2 References Text Book of Ophthalmology: Myron Yanoff, 2nd edition
American Academy of Ophthalmology-Orbits, Eyelids, and Lacrimal system (2004-05)
Duane’s ophthalmology,CD-ROM 2005
Albert and Jacobeic, CD-ROM 2003
Clinical Ophthalmology :Jack J. Kanski,5th Edition
Text book Of Ophthalmology-Peymen
Various Journals Presentation layout : 3 Presentation layout History
Clinical manifestations of thyroid eye disease
Classification ( NOSPECS)
Investigations for thyroid eye disease
Treatment History : 4 History Earliest descriptions of hyperthyroid patients with congestive exophthalmos and infiltrative dermopathy published by:
Caleb Hillier Parry in 1825;
Robert James Graves in 1835 and
Carl von Basedow in 1840. Parry Graves Introduction: : 5 Introduction: Various names
Thyroid associated orbitopathy (TAO) Introduction ( contd…) : 6 Introduction ( contd…) Organ-specific autoimmune process -strongly
associated with dysthyroidism.
Thyroid status in TAO
Primary hypothyrioidism-1% Introduction (contd..) : 7 Introduction (contd..) Both Graves' and thyroid eye disease more common in women -female to male ratio is 6:1.
Clinically apparent in approximately 50% of patients with Graves' disease
Requires intensive treatment or surgical intervention in only 3 to 5% of cases.
Mostly affects patients aged 30-50 years. Introduction ( contd..) : 8 Introduction ( contd..) Two age peaks of incidence -5th and 7th decades of life. ( seen 8-80yrs) …..AAO 2006
May precede, coincide, or follow the systemic complications of dysthyroidism.
Affects within 1 yr of development of hyperthyroidism
Progressive but self-limiting within 3-5 years. Introduction( contd..) : 9 Introduction( contd..) In the United States:
Incidence approximately 0.4%.
16 cases per 100,000 population per year-women and 2.9 cases per 100,000 population per year for men.
In a British population:
Prevalence about 2%,
Incidence 3 cases per 1000 annually.
Female: male -4:1 Introduction ( contd..) : 10 Introduction ( contd..) Familial tendency with family history of thyroid disease in approximately 30% of cases.
30 to 60% of monozygotic twins develop Graves' disease when the other twin is affected.
Increased risk of Graves' ophthalmopathy associated with cigarette smoking
( twice more in smokers) Smoking : 11 Smoking TWO hypothesis
Smokers with Graves' disease have lower concentration of soluble IL- 1 receptor antagonist than do non-smokers
Decreased inhibition of proinflammatory and fibrogenic effects of IL- 1
Increase autoimmunity Slide 12: 12 SMOKING
thiocyanate expression nicotine
Orbital hypoxia adrenergic stimulation of thyroid
direct irritative effect
localized circulatory change
release of thyroid antigen
TAO Slide 13: 13 Association : ( PARDIM)
Idiopathic thrombocytopenic purpura
Myasthenia gravis Pathophysiology : 14 Pathophysiology An autoimmune-mediated inflammation of the extra ocular muscle and periorbital connective tissue.
(Type II Hypersensitivity- ADCC )
( Type V –stimulatory hypersensitivity )
Complex immunological process involving:
TSH-receptor as the antigen,( Thyroid ,fibroblast and adipocytes)
Fibroblast and adipocytes as the effector cells,
Cytokine mediated immunologic response. Pathophysiology : 15 Pathophysiology Autoantibody against TSH receptor( TSH-R) in the Thyroid
Cross react with TSH-R in effector cells i.e. fibroblast ,adipocytes and interstitial tissue between extra ocular muscles
Inflammatory cellular infiltration ( T lymphocyte, plasma cells, macrophages and mast cells) in orbital fat,lacrimal gland and orbital interstitium Slide 16: 16 Lymphocytes infiltrate in the orbit predominantly of CD4+ and CD8+ T- cells with a few B-cells.
Interaction of CD4 T cells and fibroblast (orbital)
Release of cytokines such as IL-1b,TNF-gamma,TGF-b
Activate fibroblasts to secrete hyaluronic acid, a glycosaminoglycans.
Osmotic imbibition of water ,EOM swollen upto 8 times
Compressive optic neuropathy orbital fluid retention
Fibrosis of muscle intraorbital volume increased
Restrictive myopathy venous obstruction Proptosis Pathogenesis (Key Points): : 17 Pathogenesis (Key Points): Autoimmune Disorder (IgG mediated)
Enlargement of Extraocular Muscles
by increase in glycosaminoglycans (GAG)
Cellular Infiltration of Interstitial Tissues
with lymphocytes, plasma cells, macrophages & mast cells
Proliferation of Orbital Fat, Connective Tissue and Lacrimal Gland
with retention of fluid & accumulation of GAG Pathology : 18 Pathology Characterized by inflammation and enlargement of orbital tissues, extra ocular muscles sparing tendon
Gross examination -extra ocular muscles are enlarged, firm, rubbery, and dark red Slide 19: 19 Interstitial edema Mononuclear inflammatory cellular infiltrate
lymphocytes and plasma cells Normal looking muscle fiber Histopathology Histological findings : 20 Histological findings Progressive fibrosis late in the course of disease Intact muscle fiber Muscle replaced by fibrosis Slide 21: 21 1. Acute, active, inflammatory ( congestive)
Mediated predominantly by lymphocytes, fibroblasts
bilateral eyelid retraction, conjunctival chemosis, exophthalmos, and optic nerve compromise.
Responds to treatment Slide 22: 22 2 )Chronic, stable ( Fibrotic)
Hypertrophy and fibrosis of extra ocular muscles
Unresponsive to any suppressive treatment
White eyes Slide 23: 23 Congestive phase Fibrotic phase SYMPTOMS(OCULAR) : 24 SYMPTOMS(OCULAR) Ocular redness and irritation
Dyschromatopsia Symptoms of hyperthyroidism : 25 Symptoms of hyperthyroidism Tachycardia
Skeletal muscle weakness Tremor
Goiter Symptoms of hypothyroidism : 26 Symptoms of hypothyroidism Bradycardia
Weight gain Dry skin
Cold intolerance Ocular Signs(PECLO) : 27 Ocular Signs(PECLO) 1) Proptosis ( 60%)
2) Extra ocular motility disturbance (40%)
3) Eye-Lid signs (retraction-90%)
4) Conjuctival/corneal signs
5) Optic neuropathy ( 5%)
All signs together- 5% Proptosis : 28 Proptosis Most common cause of U/L and B/L proptosis in adults / axial and frequently permanent.
Unilateral proptosis reflects asymmetric muscle involvement.
Decreased orbital retropulsion.
Below 40- due to adipogenesis
Above 70- due to muscle enlargement and minimal adipogenesis Slide 29: 29 Axial and permanent in 70% May be associated with Choroidal folds Slide 30: 30 Extra ocular motility dysfunction : 31 Extra ocular motility dysfunction 30-50% cases, permanent
Ballet sign (restriction of one or more extra ocular muscles)
Initially due to edema , later fibrosis
All 4 recti are involved but mainly IR and MR Slide 32: 32 Restrictive myopathy Elevation defect Abduction defect Depression defect Adduction defect Signs : 33 Signs Mobius sign (poor convergence) Eyelid signs : 34 Eyelid signs More than 26 signs are described
Upper lid retraction (Dalrymple sign) -90%
with temporal flare Mechanisms for upper lid retraction : 35 Mechanisms for upper lid retraction Up gaze restriction Proptosis Fibrotic contracture of LPS
Secondary over action of LPS-SR complex
Muller muscle over action Slide 36: 36 Signs of eyelid retraction Bilateral lid retraction No associated proptosis Bilateral lid retraction Bilateral proptosis Lid lag in downgaze Unilateral lid retraction Unilateral proptosis Lid lag on down gaze (von Graefe’s sign) : 37 Lid lag on down gaze (von Graefe’s sign) Slide 38: 38 Glabellar furrows Eyelid edema Signs : 39 Signs Stellwag sign (incomplete and infrequent blinking)
Gifford’s sign (difficulty in upper lid eversion )
Goffroy sign (absent creases in the forehead on superior gaze)
Enroth’s sign (eyelid fullness) Signs : 40 Signs Kocher’s sign Gifford’s sign Conjunctival signs : 41 Conjunctival signs Deep injection over insertions of the horizontal recti
Superior limbic keratoconjunctivitis Signs : 42 Signs Goldhziar’s sign Slide 43: 43 Corneal signs Optic neuropathy : 44 Optic neuropathy (5%)
optic disc oedema or optic atrophy
due to direct compression of the nerve or it’s blood supply
May occur in absence of significant proptosis Slide 45: 45 Associated with:
Visual field loss,
Early defective color vision
Orbital congestion due to extra ocular muscle enlargement, and
Proptosis. Glaucoma : 46 Glaucoma Mechanism of the increase in IOP
Elevated episcleral venous pressure due to orbital congestion,
Contraction of the extra ocular muscles&
restrictive myopathy (intraocular pressure may rise more than 8 mm Hg on up gaze)
Chronic exposure leading to chronic inflammation and secondary angle-closure
Increased mucopolysaccharide deposit within the aqueous outflow system. Strabismus : 47 Strabismus Common
presents as hypotropia or esotropia Clinical signs of Graves' ophthalmopathy adopted by theAmerican Thyroid Association ( ATA) : 48 Clinical signs of Graves' ophthalmopathy adopted by theAmerican Thyroid Association ( ATA) Slide 49: 49 Clinical signs do not always progress in this sequence.
Disease process asymmetric between the two orbits
May undergo spontaneous exacerbations and remissions.
Limited prognostic value. Investigations : 50 Investigations Lab Studies:
Serum free thyroxine (FT4)
Thyroid stimulating hormone (TSH)
Anti-thyroid antibodies, e.g. anti-thyroid peroxidase (TPO) antibodies , TSH-R antibody
Free triiodo-thyronine (FT3) Slide 51: 51 Visual fields:
Central scotoma or
Inferior altitudinal defect in compressive optic neuropathy;
Enlarged blind spot;
Color vision: Imaging Studies : 52 Imaging Studies Ultrasound
Changes in extra ocular muscles,
Accentuation of retro bulbar fat and
Perineural inflammation of optic nerve CT/MRI : 53 CT/MRI INDICATIONS-
not needed in every cases
1) suspected optic neuropathy
3) to exclude retro bulbar tumor as a cause of proptosis Slide 54: 54 FINDINGS
Fusiform thickening of muscles with tendon sparing.
Thickening of optic nerve
Anterior prolapse of the orbital septum
Lacrimal gland enlargement without orbital erosion Slide 55: 55 Increase in orbital fat volume without muscle enlargement Management : 56 Management 1) general management of THYROID STATUS
2) Ocular Management
ii) optic neuropathy
iii) soft tissue and exposure keratopathy
iv) lid retraction
V) restrictive myopathy( strabismus) TREATMENT : 57 TREATMENT Management of THYROID STATUS
Antithyroid drugs e.g. carbimazole , methimazole, radio iodine etc.
Thyroxine replacement to suppress TSH.
Patients should stop smoking as this may worsen ophthalmopathy. Proptosis management : 58 Proptosis management 1) Steroid
indications- congestive phase ( pain/rapid progressive)
start with 60-80mg/day
Reduction of S/S usually occurs within 48 hours
Maximal response 2-8 weeks
Discontinue after about 3 months though long term maintenance may be necessary
N.B- No improvement after 3 week of oral steroid ---- stop it Slide 59: 59 2) Intravenous Methyl prednisolone
usually reserved for compressive neuropathy
Dose- 0.5 -1 gm /d for 3-5 days followed by oral prednisolone 1mg/kg for several months.
mechanism- suppression of fibroblast and lymphocytes that mediates inflammation
Reduces local inflammation and edema RELATED STUDIES : 60 RELATED STUDIES Ohtsuka et al treated 41 patients with intravenous methylprednisolone (1 g/day × 3 days) followed by 3-month oral prednisolone therapy.
Result -improvement in muscle hypertrophy but minimal effect on ocular motility and no significant effect on proptosis
( Japanese journal of ophthalmology 2002) Slide 61: 61 Macchia et al .compared 25 patients given biweekly intravenous injections of 1 g of methylprednisolone for 6 weeks, to 26 patients treated with oral prednisone for 4 to 6 months.
Results- i) patients showed significant improvement in signs and symptoms of orbital inflammation and a “slight improvement in proptosis and diplopia .”in both cases
ii) intravenous pulse therapy group required additional forms of therapy at 3 months less frequently than the oral steroid group
( ACTA Ophthalmology 2002) Slide 62: 62 2)Radiotherapy
steroid ineffective or contraindicated cases
Positive response is usually seen in 6 weeks and maximal improvement in 4 months ORBITAL RADIATION THERAPY : 63 ORBITAL RADIATION THERAPY Mechanism -Suppression of orbital lymphocytes and fibroblasts – LYMPHOLYSIS / GAG
Reduces active orbit inflammation and congestion
Minimal improvement of swollen extra ocular muscles and fat.
A cobalt-60 unit delivers total dose of 2000 cGy radiation in 10 fractions over 2 wk. Slide 64: 64 3) Combined therapy with Radiation .immunosuppressant and low dose prednisolone is more effective than any single modality.
4) Surgical decompression Surgical Decompression : 65 Surgical Decompression INDICATIONS-
1) Compressive optic neuropathy
(2) Exposure keratopathy ( Severe)
(3) Cosmesis Slide 66: 66 Exophthalmos greater than 24 mm are often candidates for orbit decompression
i)Antral-ethmoidal decompression (two wall) Most common
affords 3-6 mm of retro placement of the globe
FLOOR / MEDIAL WALL removed Slide 67: 67 Three wall decompression
FLOOR /MEDIAL/ LATERAL wall
6-10mm of retro displacement
Four wall decompression
three wall plus
lateral half of orbital roof
large portion of the sphenoid at the apex
10-16mm of retro displacement Optic neuropathy management : 68 Optic neuropathy management initially with intravenous methyl prednisolone
Orbital decompression as stated before LOCAL TREATMENT MEASURES : 69 LOCAL TREATMENT MEASURES For dry eye symptoms-
Artificial tears during the day,
Lubricating ointment at night,
Sleeping with the head of the bed elevated -decrease morning lid edema.
Taping eyelids closed at night
treat with artificial tear , ointment
orbital decompression if severe proptosis Slide 70: 70 Diplopia management
Active phase chronic phase
Simple occlusion muscle surgery
Prism (primary, reading) Strabismus Management : 71 Strabismus Management 1) Surgery
To create adequate muscle balance for fusion of images in primary and reading positions
To improve the noncomitant diplopia from restrictive myopathy of extra ocular muscles.
Time of surgery
disease is quiescent and the angle of deviation has been stable for at least 6 months
Type of surgery
recession of the Inferior and/or medial rectus with adjustable sutures that can be adjustable on first post.op.day
2) Botulinum toxin injection in the involved muscle Eyelid Surgery : 72 Eyelid Surgery Several surgical procedures are available to improve eyelid retraction, often in combinations.
The options include:
(2) Muller's and levator muscle lengthening,
(3) Lower eyelid elevation,
(4)Blepharoplasty with orbital
fat excision. Lid retraction management : 73 Lid retraction management Minor degree –not required
Usual sequence of surgery is
eyelid surgery Slide 74: 74 Retracted eye lid
Upper lid lower lid
Mullerotomy IR recession
LPS recession Slide 75: 75 Botulinum toxin treatment
To produce partial temporary denervation of restricted muscles
May have a limited role in the early course of Graves' disease. Newer modalities of treatment : 76 Newer modalities of treatment Bromocriptine:
Dopamine receptor binding agent,
Inhibition of TSH,
Anti–T lymphocyte action Slide 77: 77 Plasmapheresis, or plasma exchange therapy
Removal of humoral factors in an autoimmune process
May lead to clinical improvement
Effective in acute forms of Graves' orbitopathy,
Rebound is likely if plasma exchange is not followed with immunosuppressive therapy. : 78 Somatostatin analogue- octreotide, lanreotide
inhibit ILGF -1 in fibroblast
decrease GAG synthesis
inhibit cytokine induced GAG synthesis by fibroblast. Slide 79: 79