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Thyroid Disease
‡ Hypothyroidism
‡ Hyperthyroidism
‡ Thyroid Cancer
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Oypothyroidism
‡Low T4 & Low T3 .
‡Raised TSH (unless
pituitary problem!)
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Oashimoto¶s Disease
‡ Most common cause of
hypothyroidism (iodinated salt)
‡ It is an Autoimmune
lymphocytic thyroiditis
‡ Females > Males
‡ Runs in Families!
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Oyperthyroidism
‡ Raised T3, T4 & Low TSH
‡ Heat intolerance
‡ Weight loss (normal to
increased appetite)
‡ Tremor, Palpitations
‡ Lid retraction & Lid Lag
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0raves¶ Disease
‡ Most common cause of
thyrotoxicosis
‡ Goitre, Orbitopathy,
Dermopathy
Thyroid Eye Disease ----- Causes
TED is an eye disease associated
with disease of the thyroid gland
TED is also known as :
‡endocrine exophthalmos,
‡malignant exophthalmos,
‡Dysthyroid ophthalmopathy,
‡Ocular Graves¶ disease (OGD),
‡Thyroid associated orbitopathy(TAO)
‡Thyroid orbitopathy (TO)
‡Graves¶ ophthalmopathy
‡ Most commonly, TED occurs with an
overactive thyroid (Thyrotoxicosis),
which itself can have different causes:
-- Grave¶s disease
-- Toxic nodular goitre
‡ It also occurs in hypothyroidism, for
example with Hashimoto¶s disease
0rave¶s disease
It is the syndrome consisting of
hyperthyroidism, goitre and eye signs

‡ Autoimmune (AI) origin


‡ Excess secretion of Thyroid Hormone
by entire gland
‡ usually occurs between age group of
40s and 50s
‡ Female:Male = 8:1
 In patients with Grave¶s disease,
eye signs may precede, coincide
with or follow the hyperthyroidism

 Sometimes similar eye signs are


seen without a detectable thyroid
abnormality
Yathophysiology

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Pathogenesis (Key Points):
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 by increase in glycosaminoglycans (GAG)

‡  
 
 
 
 with lymphocytes, plasma cells, macrophages & mast cells
 Fibrosis

‡ 


  


 with retention of fluid & accumulation of GAG
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Yathology
Activated T cells, infiltrate orbital contents
and stimulate fibroblasts, leading to:

Swelling of the various tissues of the orbit


results in eyelid oedema, chemosis,
proptosis, thickening of extraocular
muscles and other signs of thyroid
ophthalmopathy.
Enlargement of extraocular muscles
‡ The stimulated fibroblasts
produce glycosaminoglycans
(GAGs) which cause the
muscle to swell
‡ Muscle size may increase by Swollen muscles
up to 8 times
‡ The swollen muscles occupy
orbital space and can
compress the optic nerve Compression
‡ These swollen muscles can of optic nerve
cause a forward propulsion of at apex of
orbit
the globe (proptosis) so that
the eyelids do not cover well
and eyes dry out, causing `  
exposure keratopathy
    

`  
   
Cellular infiltration of interstitial
tissues
‡ Lymphocytes, plasma
cells, macrophages
and mast cells
infiltrate extraocular
muscles, fat and
connective tissue

Lymphocyte cuff
Pathololgy (cont¶d)
‡ Causes degeneration
of muscle fibres
‡ Leads to fibrosis of
the involved muscle

Build up of fibrous
tissue
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Two Stages of Development
1. Active inflammation:
Eyes red and sore
Cosmetic problem
Remission within 3 years in most
patients
10% patients develop serious long-
term ocular complications
·. Quiescent stage:
Eyes are white
Painless
motility defect maybe present
Severity may range from
discomfort to blindness
( exposure keratopathy -- optic
europathy)
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·5
Five Main Clinical
Manifestations
1. Soft Tissue
Involvement
·. Eyelid Retraction
3. Proptosis
4. Optic Neuropathy /
Exposure
Keratopathy
5. Fibrosed Muscles
 
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1) Yroptosis ( 60%)

·) Extra ocular motility disturbance (40%)

3) Eye-Lid signs (retraction-90%)

4) Conjuctival/corneal signs

5) Optic neuropathy ( 5%) ·



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Signs
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üp gaze  
 Yroptosis

 
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Signs
`' (incomplete
(incomplete and infrequent
blinking)


 
(absent
(absent creases in the
forehead on superior gaze)

&( (eyelid
(eyelid fullness)

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Signs
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(difficulty in upper lid
It is a staring and frightened eversion )
appearance of the eyes

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)  
 Deep injection
over insertions of
the horizontal recti

 Chemosis

 Superior limbic
keratoconjunctivitis
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Signs
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Minimal staining

Ulceration

perforation


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 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
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Soft Tissue Involvement -
Symptoms
‡ Variable grittiness
‡ Photophobia
‡ Lacrimation - watery eyes
‡ Retrobulbar discomfort.
Soft Tissue
Involvement - Signs
‡ Periorbital and lid swelling
‡ Conjunctival and episcleral hyperaemia
Sensitive sign of disease activity
‡ Chemosis (oedema of the conjunctiva)
‡ `  
  
 
 
‡  
 
 


  
  the lacrimal glands.
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  infiltration behind the orbital
septum which may be associated with
prolapse of retroseptal fat into the eyelids

Severe periorbital swelling in thyroid eye disease


› 
  
   
  sign of inflammatory
activity. Intense focal hyperaemia
may outline the insertions of the
horizontal recti.
Soft Tissue Involvement - Rx
Frequently unsatisfactory, may be of some
benefit
‡ Topical Rx  lubricants (artificial tears &
ointment) reduce irritation caused by
conjunctival inflammation and mild corneal
exposure
‡ Elevating the head end of bed during sleep may
decrease periorbital oedema. Diuretics given at
night may also reduce the morning
accumulation
‡ Taping of eyelids at night may be useful for mild
exposure keratopathy
Eyelid Retraction
‡ Retraction of both upper and lower eyelids occur in
50% of patients
‡ Normally, upper eyelid rests about ·mm below limbus,
with lower eyelid resting at the inferior limbus
‡ When retraction occurs, the sclera (white) can be seen
‡ Causes cosmetic problems
‡ Pathogenesis not clear
‡ May be due to contraction of the levator muscle by
fibrosis, or be chemically induced by high thyroid
hormone levels
‡ If persists when disease is inactive, can be helped by
eye lid surgery
Eyelid Retraction  Clinical
Features
‡ Clinical signs:
 Lid retraction in
(front) gaze
 Lid lag i.e.
delayed descent
of upper lid in
downgaze
 Staring
appearance of
the eyes
Eyelid Retraction - Rx
‡ Mild eyelid retraction does not require Rx, in
50% of cases, there is spontaneous
improvement
‡ Rx of associated hyperthyroidism may also
improve lid retraction
‡ Main indications are exposure keratopathy and
poor cosmesis
‡ Treatment is surgical if required, when both the
eyelid retraction and thyroid are stable
‡0   
  
retraction caused by overaction. of Muller's muscle.
Proptosis
It is defined as forward displacement of the eyeball beyond the
orbital margins.
‡ Proptosis is axial
‡ TED is the most common cause
of both bilateral and unilateral
proptosis in adults
‡ Proptosis is uninfluenced by
Rx of hyperthyroidism and is
permanent in 0% of cases
‡ Severe proptosis prevents
adequate lid closure, and may lead to
severe exposure keratopathy and
corneal ulceration
Proptosis - Rx
‡ Systemic steroids to reduce
inflammation
‡ Low dose radiotherapy
‡ Surgical decompression: This is
where one or more walls of the orbit
are removed causing an increase in
space and relief of the proptosis. In
extreme cases, all four walls may be
removed
Optic Neuropathy
‡ Serious complication affecting about 5% of
patients
‡ Caused mainly through direct compression
of the optic nerve or its blood supply by
enlarged and congested rectus muscles at
the orbital apex
‡ May occur in the absence of proptosis
‡ Can cause severe but preventable visual
impairment
Optic Neuropathy  Clinical
Features
‡ An early sign is decreased colour
vision
‡ Slow progressive impairment of visual
acuity
‡ Visual defects, especially central
scotomas
‡ Optic atrophy in chronic advanced
cases
Optic Neuropathy - Rx
‡ Depends on severity
‡ Initial RX by systemic steroids and/or
radiotherapy
‡ Orbital decompression is considered
if above is ineffective or optic nerve
severely involved
Ocular Motility Problems
‡ Between 30% and 50% of dysthyroid
patients develop eye movement problems
‡ The diplopia caused by this may be
transient, but in many, it is permanent
‡ Ocular motility is restricted by oedema in
the infiltrative stage and fibrosis during the
fibrotic phase
‡ A defect in elevation is most common due
to fibrosis of inferior rectus tethering eye
Rx of Ocular Motility Problems
‡ Surgery is usually considered if there is diplopia
in primary gaze or reading position
‡ Diplopia must have been stable for about 6
months
‡ Rx is by muscle surgery, with the aim of
producing binocular vision when looking
forward, and good cosmetic result
‡ Botulinum toxin injection (Botox) to relax
muscles may be useful in selected cases
  
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not needed in every
cases

‡ 1) suspected optic
neuropathy

‡ ·)before decompression

‡ 3) to exclude retro
bulbar tumor as a cause
of proptosis

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Increase in orbital fat volume without muscle
enlargement

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Swollen muscles
Compression
`   `  
    of optic nerve

     at apex of
orbit
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