! Women greater than men (4:1)» Typical of other autoimmune diseases

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1 : Overview and Diagnosis Suzanne K. Freitag, M.D. Director, Ophthalmic Plastic Surgery Massachusetts Eye and Ear Infirmary Harvard Medical School! I have no financial disclosures. Learning Objectives! To discuss the epidemiology of thyroid conditions! To review the clinical findings of patients with thyroid-related orbitopathy! To discuss testing recommended in these patients, including radiology and blood tests! Grave s disease» described in 1825 by Parry & 1835 by Graves as a triad of findings» Goiter» Tachycardia» exophthalmos 5 6 A COMMON PROBLEM! Hyperthyroidism: incidence of 1-2% in US! 30-70% of these develop orbital disease! 5% have serious sight-threatening disease! May be hyperthyroid, hypothyroid or euthyroid» Graves, Hashimotos, etc! Women greater than men (4:1)» Typical of other autoimmune diseases

2 » Typical of other autoimmune diseases 7 8! Bimodal age distribution» Women years (most common) years» Men years years! 16% of women and 34% of men have no thyroid abnormality on presentation ! majority of euthyroid patients WILL develop thyroid systemic disease! Close temporal relationship between onset of Graves disease and TED either condition may occur first 80% develop within 18 months of each other Signs and Symptoms of TED! dry eyes/ ocular irritation (most common)! Proptosis! Conjunctival injection & chemosis! eyelid retraction (very specific)! lid lag! lid edema & erythema! Elevated IOP 2! lagophthalmos! extraocular muscle enlargement» Motility restriction --> diplopia,» reduced Bell s! Corneal exposure optic neuropathy

3 Corneal exposure! optic neuropathy! subluxation of globe Dry Eye Proptosis & Lid Retraction Chemosis Lid Lag Lid Edema Lagophthalmos Subluxation of Globe TED Optic Neuropathy! Most common cause of unilateral or bilateral proptosis.! Most common disease producing orbital signs and symptoms.! A clinical diagnosis..» There is no single clinical finding or lab test that is diagnostic.! Each patient with TED has unique constellation of signs and symptoms TED Diagnosis! Careful history and physical exam! Thyroid function tests! +/- Orbital imaging» i.e. euthyroid, unilateral proptosis TED Diagnosis! If I could do only one clinical examination test RESISTANCE TO RETROPULSION TED Differential Diagnosis! Proptosis» Primary cancer» Metastasis

4 2» Metastasis» Orbital meningioma» Orbital myositis» Sarcoidosis» Wegeners» CC fistula» Sinus mucocele» Contralateral orbital fracture! Lid retraction» Midbrain syndrome» Contralateral ptosis» Sympathomimetic drugs TED Diagnosis! Consider blood testing if diagnosis is in question.» TSH, T3, T4» Thyroglobulin antibodies» Thyroid peroxidase antibodies» TSH receptor antibodies TED Imaging CT or MRI! Fusiform enlargement of EOM s» tendon sparing! Order of muscle involvement» IR, MR, SR, LR! Therefore HYPO and ESO tropias common 27 2! Obliques may also be involved! Check orbital apex for EOM s crowding optic nerve! Scans are necessary for surgical planning! MAY have normal muscles and increased FAT volume CT and MRI

5 CT and MRI Imaging Symmetric and Asymmetric Apical Crowding Muscle Enlargement versus Fat Hypertrophy Fat Hypertrophy and Lacrimal Gland Enlargement Enzmann et al. J Comput Assist Tomogr 1979.! Subclinical orbit involvement is common! 70% of hyperthyroid patients show changes on CT or MRI 34! Runs a fairly predictable course» RUNDLE s CURVE! Inflammatory stage (6 to 24 months)» Erythema, edema, worsening of disease» May have fluctuations, even daily! Stable plateau Francis Felix Rundle! Born in 1910 in Australia! Studied medicine at U of Sydney! Moved to London and trained as thyroid surgeon! Major interest was thyroid orbitopathy! Perros et al. Clin Endocrinol 1995.» Patients with TED for 12 months» 2/3 had improvement in ocular manifestations» Stability in 20%» Worsening in 14%

6 Acute and Chronic TED! Counsel patients that they shouldn t expect to look the way they did before the disease. Disease Severity Score! NOSPECS classification SCORE Feature 0 N no signs or symptoms 1 O only signs, no symptoms 2 S soft tissue involvement 3 P proptosis 4 E EOM involvement 5 C corneal involvement 6 S sight loss 40 Clinical Activity Score (CAS)! Range 0 10! May help predict response to treatment! One point each for the presence of:» Chemosis, lid swelling, lid erythema, conj erythema, caruncle swelling, pain in primary gaze, pain with eye movement» active score = 3 or more out of 7! One point each for interval worsening of:» Visual acuity, diplopia, proptosis» active score = 4 or more out of TED Quality of Life (QOL)! TED can have a devastating effect on QOL» Physical and mental health» Poor self-image, sleep disturbance, impaired social and work function! Several QOL questionnaires have been developed

7 42 Thank you