The Eye & General Medicine

1. The Eye & General Medicine Exophthalmos & thyroid eye disease A case report for a ‘Grand Round’ Good Hope Hospital, March 2003 David Kinshuck, Associate Specialist, Eye Clinic

2. Case: Thyroid eye disease (Graves) • 46y female • 1998 (41y) thyrotoxicosis, treated with antithyroid drugs • 1999 radioactive iodine (systemic steroids 2 months) • 2001 exophthalmos, active, referred • 2003 stable, but expecting treatment • Unhappy with appearance • Sore gritty watery eyes

3. Appearance • Upper lid retraction • Lower lid retraction • Exophthalmos (proptosis) • Dry eyes • Soft tissue lid swelling • Symptoms • Sore eyes/dry eyes/watery • Appearance • Optic nerve damage • glaucoma

4. Pathology, basis • Enlarged ocular muscles & soft tissues • Glycoproteins accumulate inside cells, lipid accumulation, lymphocytes, fibrosis • Pushes eye forward… exophthalmos • Or presses on optic nerve (blindness) • Eye movements reduced, squints

5. What is happening in the orbit

6. Hypothroidism increases TSH Receptors increase with smoking

7. Cell swells up with glcycoproteins etc

8. What do we do in eye clinic Have to identify if active, and how active, and try and predict prognosis with and without

12. What do we do in eye clinic

13. What do we do in eye clinic

14. What do we do in eye clinic

15. What do we do in eye clinic

16. Proposed Classification System to Assess Disease Activity in Thyroid Eye Disease. One point is given for each sign present. • PainPainful, oppressive feeling on or behind the globePain on attempted up, side, or down gazeRednessRedness of the eyelidsDiffuse redness of the conjunctivaSwellingChemosisOedema of the eyelid(s)Increase proptosis of 2 mm or more during a period between 1 and 3 monthsImpaired functionDecrease in visual acuity of 1 or more lines on the Snellen chart (using a pinhole) during a period between 1 and 3 monthsDecrease of eye movements in any direction equal to or more than 5 degrees during a period of time between 1 and 3 months • (From Mourits et al)

17. Signs of activity: • Puffiness increasing • exophthalmos increasing • pain increasing • patient is reasonable judge • optic nerve compression/field loss • diplopia beginning • all this early on in disease, unusual after 1 year

18. Treatment in active phase • If active AND sight threatened, or proptosis disfiguring, systemic steroids(or it is reasonably clear this is likely) • If activity continues despite steroids, radiotherapy to orbits • Can decompress orbit surgically as alternative • Soft tissue activity only, no proptosis, so no steroids • Depends on ‘activity’ score

19. Can be difficult to determine whether disease is active • Best results are when (severe cases) are given steroids early • Don’t really know which the ‘severe’ cases are early on Threshold for steroids

20. Threshold for steroids Red=very active=proptosis/optic atrophy black=intermediate=some proptosis green=soft tissue changes that will resolve Thyroid eye disease activity score

21. Threshold for steroids

22. Threshold for steroids

23. Threshold for steroids At onset difficult to judge outcome………………….

24. Our patient • Stable appearance for 2 years • Smokes, best to stop (may not make much difference at this stage) • Offered referral for cosmetic surgery • Lid surgery (insert ‘spacer’ material) • possibly orbit surgery, more complex/risky

25. Illustrates problems in medicine (life) generally • Treatments get more effective, more is known, making tremendous progress • powerful treatments, side effects, • often hard to decide at the time what to do • sub-specialty training helps, but patients will not present to the expert initially • treatment windows:leaving things late causes problems • hard data lacking: cannot be trained for all problems