THYROID EYE DISEASE –

INVESTIGATION AND
MANAGEMENT
KISHAN S
51
INVESTIGATIONS

• 1. Thyroid Function tests. These should include: serum T3, T4,

TSH and estimation ion of radioactive iodine uptake.
• 2. Thyroid autoantibody assay may include anti TSH
receptors, anti-thyroid peroxidase, antithyroglobulin, and
thyroid stimulating antibodies.
• 3. Ultrasonography. It can detect changes in extraocular muscles even in
class O and class 1 cases and thus helps in early diagnosis. Enlargement of
the extraocular muscles without enlargement of tendon in the hallmark of
thyroid ophthalmopathy. In addition to the increase in muscle thickness,
erosion of temporal wall of orbit and perineural inflammation of optic
nerve can also be demonstrated in some early case .
• 4. Computerised tomographic scanning. It may show proptosis, muscle
thickness, thickening of optic nerve and anterior prolapse of the orbital
septum (due to excessive orbital fat and/or muscle swelling)
• 5. MRI (T2-weighted and STIR) gives better soft tissue resolution and
identifies active disease.
MANAGEMENT

• Management of TED includes:

• Periodic clinical work up,
• Non-surgical measures, and
• Surgical management.
 PERIODIC CLINICAL WORK UP

• It is essential to document the clinical course of the disease periodically to decide the
treatment required and to monitor the effect of therapy.
• Clinical activity score has been described to measure the activity of disease at a given time.
Total score is noted by giving a score of 1 for each of the following 10 features:
• Pain: 1. Retrobulbar pain, 2. Pain on ocular movement,
• Redness: 3. Redness of lids, 4. Redness (congestion) of conjunctiva,
• Swelling: 5. Swelling of lids, 6. Swelling (chemosis) of conjunctiva, 7. Swelling of caruncle,
8. Proptois (~ 2 mm increase in proptosis over 1-3 months,
• Loss of function: 9. Decrease in eye movement by± 5° over 1-3 months, 10. Decreased
vision by_+1 Snellen line over 1-3 months.
Ocular motility work up
• In addition to eye movements, the ocular motility workup should also
include:
• Field of binocular single vision.
• Field of uni ocular fixation, and
• Hess/Lees charting to decide the intervention required.
NON SURGICAL MANAGEMENT

• 1.Smoking cessation should be insisted with the patients as it may markedly influence the
course of disease.
• 2. Head elevation at night and cold compresses in the morning help in reducing
periorbital oedema.
• 3. Lubricating artificial tear drops instilled frequently in the day time and ointment at bed
time are useful for relief of foreign body sensation and other symptoms of dry ocular
surface.
• 4. Eyelid taping at night prevents complication of exposure.
• 5. Guanethidine 5% eye drops may decrease the lid retraction caused by overaction of
Muller's muscle.
• 6. Prisms may be prescribed to alleviate annoying diplopia till the quiescent phase is
reached.
• 7. Systemic steroids may be indicated in acutely inflamed orbit with rapidly progressive
chemosis and proptosis with or without optic neuropathy.
• 8. Radiotherapy. 2000 rads given over 10 days period may help in reducing
orbital oedema in patients where steroids are contraindicated.
• 9. Combined therapy with low dose steroids, azathioprine and irradiation
is reported to be more effective than steroids or radiotherapy alone.
SURGICAL MANAGEMENT

• During active phase, orbital decompression may be required for an

acutely progressive optic neuropathy and/or exposure keratitis, in patients
who do not respond to energetic steroid therapy.
• During quiescent burn-out phase, the surgical management is required to
improve function and cosmesis.
• A stepwise surgical approach, starting with orbital decompression
followed by extraocular muscle surgery, followed by eyelid surgery is
recommended. Alteration of this sequence may lead to unpredictable
results.
• 1. Orbital decompression may be carried out by an external or endoscopic
approach and may involve 2, 3 or 4 walls:
• •Two-wall decompression, in which part of the orbital floor and medial wall
are removed, allows 3-6 mm of replacement of the globe.
• Three-wall decompression involves removal of parts of the floor, medial
wall and lateral wall, and allows about 6-10 mm of retroplacement of the
globe.
• Four-wall decompression involves removal of lateral half of roof and large
portion of sphenoid at the apex, in addition to three-wall removal as above.
This allows 10-16 mm of retroadditiont of the globe and is indicated very
rarely in patients with severe proptosis.
• 2.Extraocular muscle surgery should always be carried out after the
orbital decompression, since the latter may alter extraocular motility.
Extraocular muscle surgery in the form of recession is required to achieve
binocular single vision in the primary gaze and reading position. Inferior
rectus recession is the most commonly performed surgery.
• 3. Eyelid surgery, when required, should be undertaken last, as the
extraocular muscle surgery may affect eyelid retraction. As temporaiy
measures, before the definitive surgical correction, the botulinum toxin
injection aimed at Muller’s muscle and LPS muscle may be used.
• Eyelid surgery for definitive correction may include:
• Mullerectomy, i.e. disinsertion of Muller's muscle is required for mild lid
retraction.
• Levator recession/disinsertion may be required for moderate to severe
upper eyelid retraction.
• Scleral grafts with LPS recession may be required in very severe cases.
• Recession of lower eyelid retractors may be required to correct more than
2 mm retraction of lower eyelid.
• Blepharoplasty. It may be performed by removal of excess fatty tissue
and redundant skin from around the eyelids.
REFERENCE

• Comprehensive Ophthalmology, A K Khurana.

Thank you