Case Presentation

Thyroid Associated Opthalmopaty ODS

Irwani Mandalika

FACULTY OF MEDICINE MATARAM UNIVERSITY

NTB PROVINCE GENERAL HOSPITAL
2018
 INTRODUCTION
 Most people with thyroid eye disorders due to autoimmune Graves disease

 Graves' disease can be found in eye abnormalities in the form of pretibial edema,
chemosis, proptosis, diplopia, and decreased vision. Patients with classic Grave's
disease show symptoms of thyroid enlargement, thyrotoxicosis, abnormalities in
the eyelids, and exophthalmus which can be unilateral or bilateral.

 The prevalence of Graves ophthalmopathy is more common in women (2.5-6

times more often than men) in the age range of 30-50 years
 IDENTITY

 Name : Mrs.M
 Sex : Female
 Age : 35 years old
 Religion : Islam
 Address : Masbagik, Lotim
 Anamnesis

 Main complaint : both eyes protruding

Disease History :
- complaints of both eyes protruding since1.5 years ago
- Complaints worsen about 1 week ago. the patient also complained pain in both eyes and blurred vision (+)
- Other complaints such as cold sweat (+), tremor (+), heart palpitations (+), fatigue (+)
- there is no history of trauma to the eye

- Complaints of headache nausea and vomiting are also denied .

Past Disease History :
 Past eye disease (-), History of hyperthyroidism since 1.5 years ago
 History of hypertension (-), history of diabetes mellitus (-)

Treatment History:
History of thyroid treatment: propylthiouracil 1 x 100 mg, Propanolol 1 x 30 mg

Family disease history :

 A family history of eye disease (-), hypertiroid (-), hypertension (-) and diabetes mellitus is (-)

History of allergy
 Foods (-) Drugs (-)
 Physical examination

General impression: Mild Pain

Awareness: compos mentis
Vital sign:
• BP : 120/70 mmHg
• HR: 82x / minute
• RR: 20x / minute
• Temperature: 36.7 C
 Ophthalmologic
No Eye Examination Okuler Dekstra (OD) Okuler Sinistra (OS)

1. Visus Naturalis 6/15 6/24

Pinhole 6/15 6/24

2. Ocular Position Orthophoria Orthophoria

3. Ocular motility

4. Visual field
 5. Superior Eyelid Edema (-) (-)
Hematoma (-) (-)
Entropion (-) (-)
Ectropion (-) (-)
Ptosis (-) (-)
Exoftalmus (+) (+)
Lid retraction (+) (+)
6. Inferior eyelid Edema (-) (-)
Hematoma (-) (-)
Entropion (-) (-)
Ectropion (-) (-)
7. Superior palpebral conjunctiva Hyperemia (-) (-)
Scar, Anemia (-) (-)
8. Inferior palpebral conjunctiva Hyperemia (-) (-)
Scar, Anemia (-) (-)
9. Cnjunctival layer of bulb Conjungtival injection (-) (-)
10 Cornea Shap convex convex

Clarity Clear clear

Surface Smooth Smooth

Scar (-) (-)

12 Anterior chamber Depth Seems normal in depth Seems normal in depth

.
13 Iris Colour Brown Brown
.
Shape Reguler Reguler

Anterior Synechia (-) (-)

Posterior synechia (-) (-)

14 Pupil Shape Round, Ø ± 3 mm Round, Ø ± 3 mm

. Direct reflex (+) (+)

Indirect (+) (+)

15 Lens Clarity Clear Clear
. Iris Shadow (-) (-)
Subluxation (-) (-)

Dislocation (-) (-)

16. Intraocular Palpation N /P N /P

pressure
17 Funduscopy Fundus refleks (+) (+)
 Pemeriksaan hertel eksoftalmometri

17 111 17
 Pemeriksaan Laboratorium (05/04/2018)
Pemeriksaan Hasil

FT4 29,75

TSH <0,05
 PROBLEM IDENTIFICATION

SUBJECTIVE
OBJECTIVE
 The patient complained of protruding eyes since 1.5  VOD 6/15, VOS 6/24
years ago.
 Visions with pinholes have no improvement
 Prominent eyes accompanied by pain and blurred
 Lens examination ODS: clear
vision slowly
 Funduskopi ODS: refleks fundus (+)
 Case Analysis

Selulitis Orbita Tumor Orbita

Thyroid
Associated
Opthalmopaty
 Orbital cellulitis is suppurative inflammation of the loose intraorbular connective
tissue behind the orbital septum

 Orbital cellulitis will give symptoms of fever, red eyes, edema eyelids, eye
proptosis, decreased vision sharpness. Unilateral.

 laboratory examination, leukocytosis was found as a marker of infection, and T3,

T4 and TSH examinations were within normal.
 Orbital tumors are tumors located in the orbital cavity

 Clinical symptoms consist of proptosis which is usually unilateral, Proptosis, painless,

endocrine exophthalmos or carotid-cavernous fistula. Palpation can show a mass that
causes distortion of the petals or eyeball. Sharpness of vision goes down.

 A CT scan is needed to see the location of orbital tumor mass and can distinguish
whether proptosis is caused by muscle and fat enlargement such as TAO or because of
a tumor.

 T3, T4 and TSH tests are also at normal levels.

 Ophthalmopathy Grave can also be called thyroid associated orbitopathy (TAO) an
autoimmune condition with abnormal thyroid level status

 there is severe inflammation that causes remodeling of orbital tissue, including the
accumulation of extracellular macromolecules and fat

 This condition is characterized by eyelid retraction, proptosis (protrusion of the eyeball to

the outside), restrictive extraoclular myopathy, and optic neuropathy.

 Thyroid function tests, as in hyperthyroid disease, T3 and T4 levels are increased, FT4
increases, and TSH decreases
The American Thyroid Association classifies grave ophthalmopathy degrees from a
scale of 0 to 6 known as "NO SPECS" criteria
 Assessment

 Diagnosis kerja : Thyroid Associated Opthalmopaty ODS

 Diferrential Diagnosis
 Tumor orbita
Management

 Metilprednisolone 8 mg 3-3-0
 Cendo Lyteers ed 6 x ODS
 Planning

 Orbital CT scan
Prognosis

 Quo ad functionam  Dubia ad bonam

 Quo ad vitam  Dubia ad bonam
REFERENCE

 Iljas, S. 2007. Ilmu Penyakit Mata, Edisi 3. Jakarta; Fakultas Kedokteran Universitas
Indonesia
 Riordan, Paul dkk. 2010. Vaughan & Asbury Oftalmologi Umum, Edisi 17. Jakarta; EGC
 Budiono, S dkk. 2012. Buku Ajar Ilmu Kesehatan Mata. Surabaya; Fakultas Kedokteran
Universitas Airlangga
 Perhimpunan Dokter Spesialis Mata Indonesia, 2006, Panduan Manajemen Klinis
Perdami. Jakarta ; PP Perdami
Thank you ...