GRAVES OPHTHALMOPATHY

Referred to as :

Graves Disease Thyroid Orbitopathy Thyroid Eye Disease (TED) Thyroid Associated Ophthalmopathy (TAO)

What is it ?
Graves Disease is an autoimmune disease, which involves both orbital tissues and the thyroid gland.
Produce a variety of oculoplastic problems ranging from periocular swelling to blindness caused by optic nerve compression

Who gets Graves Ophthalmopathy ?

Eye problems are most commonly associated with Graves Disease ( up to 50% of patients may have signs if examined carefully ) In rare cases it can affect patients with thyroid carcinoma Women are much more commonly affected then men

What causes Graves Ophthalmopathy ?

Complex and not fully understood Occurs about 12 -18 month after the development of hyperthyroidsm Can affect people with Euthyroid or Hypothyroid

Antibodies like those active against the thyroid damage the soft tissues in the orbit ( the bony socket of the eye )

producing inflammation with enlargement of the muscle and the fat around the eye

Factors that affect the development Graves Ophthalmopathy

Heredity ( 30% have a family history ) Stress Smoking Environment

1. 2. 3. 4.

Signs and Symptoms

Non infiltrative Ophthalmopathy - widening of the palpebral fissure - lag of the globe on upward gaze, or - lag of the upper lid on downward gaze

cause the eyes to appear exophthalmic, but there is no proptosis

Infiltrative Ophthalmopathy - Edema of the palpebra contents - Protrusion of the globe - Infiltration of the extraocular muscle - Damage to the optic nerve and the retina - Increased IOP

Classification of the Ocular Changes in Graves Disease

Many problems from Graves Ophthalmopathy

Lid retraction ( upper lid too high or lower lid too low ) Double vision Bulgy eyes Swelling of the eyelids and eyeballs Blurry vision or loss of vision Trouble closing the eyelids and dryness of the eyes / watering of the eyes

The photo show a patients with marked upper lid retraction and bulging of the eyes

Bulging red eyes in thyroid eye disease

23 y/o woman presents with the chief complaint of nervousness. She has a one month history of increased nervousness associated with a short temper, crying easily, and tremor. In addition she states she has lost 25 pounds without dieting, and is always hot. Her eyes protrude and feel dry.

Pathology
Involves histologic abnormalities in orbital tissue including :
- extraocular muscles - orbital fat - lacrimal glands ,and

- interstitial connective tissue

Extraocular muscle from a patients with graves disease and infiltrative ophthalmopathy

Edematous orbital fat and cellular infiltrate

Lacrimal gland with mononuclear infltrate, fibrosis and an increase in ground substance

End stage in severe involvement of extraocular muscles in ophthalmopathy

What tests are performed in patients with Graves Ophthalmopathy ?

- Re-check of thyroid function - VA - Assessment of eyelid position and function - Slit lamp exam. of the surface the eye - Pupil testing ( a test of optic nerve function ) - Test of IOP - Color vision testing - Eye movement assessment - CT or MRI of orbits ( to look at the tissue around the eyes ) - Ultrasound scan of the eye muscles

Enlarged muscle on the left side compared to the right on an MRI scan

Clinical Activity Score ( CAS )

( Table 1 )

To assess treatment of active inflammatory ophthalmopathy To predict therapeutic outcome To select patient for surgical or non surgical treatment

Table 1. Proposed classification System to assess Disease activity in Graves ophthalmopathy

Pain Painfull, oppresive 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

Edema of the eyelids

Increase proptosis of 2 mm or more during a period between 1 and 3 Months Impaired function Decrease in VA OF 1 or more lines on the Snellen Chart during a period between 1 and 3 months Decrease of the eye movements in any durection equal to or more 5 degrees during a period of time between 1 and 3 months

One point is given for each sign present. The sum of these points defines the activity Score.

Treatment
Depends on the severity of signs and symptoms Acute episodes of inflammation result in double vision and optic nerve compression recommend HIGH DOSE-ORAL STEROIDS ( PREDNISON )

Radiation therapy !!! radiation retinopathy

Surgical procedures : - orbital decompression ( to decrease proptosis ) - strabismus surgery ( to realign the eyes ) repair of double vision - lowering of the upper eyelids - raising the lower eyelids, and - blepharoplasty 3 to 5 years after onset

Written by Nisa