Transcript OCULAR MANIFESTATIONS OF THYROID DISEASE

OCULAR MANIFESTATIONS
OF THYROID DISEASE
Graves ophthalmopathy
Other names: thyroid eye disease, thyroid
orbitopathy
 Autoimmune inflammatory disorder whose
underlying cause continues to be elucidated
 Signs and symptoms may progress and abate
independently of other clinical features
 Eye findings may occur even in the absence of
objective evidence of thyroid dysfunction
(euthyroid Graves disease)

Graves ophthalmopathy
o
Ophthalmopathy may relate to antibodies
that cross-react with TSH-R antigens
expressed on orbital fibroblasts
PATHOGENESIS:

Theories:
 Glycosaminoglycans
expressed from
fibroblasts causes secondary water retention
and therefore, retrobulbar swelling
 TSH-R as the antigen

Fusiform enlargement of extraocular muscles;
sparing of tendons
Little enlargement of extraocular muscles but marked
increased in the orbital fat may occur.
Diagnostic criteria for Graves
ophthalmopathy
Key points about Grave’s disease:
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Most common cause of eyelid retraction
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Most common cause of bilateral or unilateral proptosis.
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More common in women
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Associated with hyperthyroidism in 90% of patients; 6% are
euthyroid

Smoking is associated with increased risk and severity of
ophthalmopathy.
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The course of ophthalmopathy does not necessarily parallel
the activity of the thyroid gland or the treatment of thyroid
abnormalities.
Grave’s disease/Thyroid
Ophthalmopathy
Clinical signs
 Eyelid retractionmost common sign
 Lid lag
 Proptosis
 Restrictive extraocular
myopathy
 Optic neuropathy
Other clinical features:
Most frequent ocular symptom is pain or
discomfort (30%)- often the result of dry
eyes
 Diplopia- 17%
 Lacrimation/photophobia- 15-20%
 Blurring of vision- 7.5%

Non-ocular clinical findings:
Thyroid dermopathy- 4%
 Thryroid acropachy-1%
 Myasthenia gravis- 1%
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A. Bilateral proptosis and upper eyelid retraction
B. Marked chemosis, eyelid swelling and increased
proptosis
• Bilateral lid retraction
• No associated proptosis
• Bilateral lid retraction
• Bilateral proptosis
• Unilateral lid retraction
• Unilateral proptosis
• Lid lag in downgaze
Soft tissue involvement
Periorbital and lid swelling
Chemosis
Conjunctival hyperaemia
Superior limbic
keratoconjunctivitis
Proptosis
• Occurs in about 60%
• Uninfluenced by treatment of hyperthyroidism
Axial and permanent in about 70%
May be associated with choroidal folds
Treatment options
• Systemic steroids
• Radiotherapy
• Surgical decompression
Optic neuropathy
• Occurs in about 6%
• Early defective colour vision
• Usually normal disc appearance
Caused by optic nerve compression at Often occurs in absence of significant
orbital apex by enlarged recti
proptosis
Restrictive myopathy
• Occurs in about 40%
• Due to fibrotic contracture
Elevation defect - most common
Depression defect -uncommon
Abduction defect - less common
Adduction defect - rare
Treatment:
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Correction of thyroid function abnormality
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Anti-thyroid drugs
Radio active iodine
thyroidectomy
Orbital decompression- to treat optic
neuropathy, orbital congestion, advanced
proptosis
 Topical ocular lubricants
 Corticosteroid treatment
 Orbital radiotherapy- targets lymphocytes?
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Treatment and Prognosis:
Self limiting, but….
 may run an active course of exacerbation
and remissions
 Therapy directed toward decreasing
orbital congestion and inflammation or
expanding the bony volume
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Treatment and Prognosis:
Often improves with establishment of
euthyroid state, but eye disease may
continue to progress
 Elective orbital decompression, strabismus
surgery and eyelid retraction repair usually
are not considered until a ophthalmic
signs have been stable for 6-9 months.
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