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Thyroid Eye Disease.pptx

  1. Thyroid Eye Disease Sarah Al Ghadban
  2. CONTENTS 1. Introduction 2. Etiology 3. Risk Factors 4. Epidemiology 5. Pathophysiology 6. Diagnosis 1. History/Symptoms 2. Signs 7. Diagnostic Procedures 1. Laboratory Test 2. Imaging 8. Differential Diagnosis 9. Grading 10. Management 11. Complications
  3. ● TED is an autoimmune disease caused by the activation of orbital fibroblasts by autoantibodies directed against thyroid receptors. ● Rare disease: Incidence 19 in 100,000 people per year ● Characterized by: enlargement of the extraocular muscles, fatty and connective tissue volume. ● Graves' disease (GD): autoimmune disorder involving the thyroid gland ○ Presence of circulating autoantibodies that bind to and stimulate the thyroid hormone receptor (TSHR), resulting in hyperthyroidism and goiter. ○ Organs other than the thyroid can also be affected, leading to the extrathyroidal manifestations. ● TED is observed in ~ 50% of patients with GD ● Previously known as thyroid-associated ophthalmopathy (TAO), Graves orbitopathy (GO) and other variations. INTRODUCTION
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  5. Normal-functioning (Euthyroid) or under- functioning thyroid (Hypothyroidism e.g. Hashimoto's thyroiditis) 10% of patients The course and severity of ocular manifestation does not always correlate with thyroid hormone levels. Treatment of thyroid dysfunction does not necessarily affect course of Grave’s ophthalmopathy. TED is most frequently associated with Hyperthyroidism 90% of patients Etiology
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  8. Both men and women demonstrate a bimodal pattern of the age of diagnosis. The median age is 43 years for all patients, with a range from 8 to 88 years old. Women are affected five times more than men. Linked to a higher incidence of Grave's disease in women. Epidemiology
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  10. Activation of orbital fibroblasts by Graves' disease-related autoantibodies Release of T cell chemoattractants Fibroblasts expressing extracellular matrix molecules, biologic materials proliferating and differentiating into myofibroblasts or lipofibroblasts and deposition of glycosaminoglycans Bind water that lead to swelling, congestion in addition to connective tissue remodeling Extraocular muscle enlargement and orbital fat expansion.
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  12. History/Symptoms Gritty Sesnations and photophobia Forward protrusion of the eye = Exophthalmos In more advanced cases eye socket (orbital) pain, double vision, or blurred vision. Lacrimation or dry eye
  13. Eyelid retraction (Dalrymple's sign) is the most common presenting sign of TED, present in upto 90% of patients Eyelid retraction in patient with TED. Upper lid retraction measured with margin to reflex distance 1 (MRD1) and lower lid retraction measured with margin to reflex distance 2 (MRD2). Signs
  14. TED is the most common cause for both unilateral and bilateral axial proptosis (exophthalmos). Increased resistance to retropulsion. Hertel’s exophthalmometer is used for the measurement of proptosis. Signs
  15. Extraocular muscles frequently involved in TAO. Extraocular muscles affected results in ocular misalignment, diplopia. Inability to look up when the eye is adducted i.e. double elevator palsy. Signs
  16. Stellwag sign- Incomplete and infrequent blinking (staring look) Grove sign- Resistance in pulling the retracted upper eyelid Boston sign- Jerky movements of eyelids in downgaze Gifford sign- Difficulty while everting the upper eyelid Gellineck sign- abnormal pigmentation of upper eyelid Upper Lid Signs
  17. Enroth sign- lower eyelid edema Griffith sign- Lid lag on upgaze Lower Lid Signs
  18. Goldzheir’s sign conjunctival injection Conjunctival Signs
  19. Mobius sign- Not able to converge eyes Ballet's sign- One or more extraocular muscle restriction Suker sign- Poor fixation in abduction Jendrassik's sign- paralysis of all EOM = Total ophthalmoplegia Extraocular movements signs
  20. Knies sign- Uneven pupillary dilatation in dim light Cowen sign- Jerky contraction of the pupil to light Pupillary signs
  21. Vigouroux sign- eyelid fullness Von Graefe sign- retarded descent of upper lid in downgaze Jofforoy sign- absent crease of the forehead in superior gaze Kocher's sign- Staring and frightened appearance of eyes Generalized Signs
  22. Clinical Course The pattern of the disease follow the Rundle’s curve which describe the plot of orbital disease severity against time
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  24. The diagnosis can be done clinically with the characteristic clinical picture, restrictive nature of the disease and associated systemic thyroid disease. Though not diagnostic, thyroid hormone levels, thyroid-stimulating immunoglobulins (TSI), anti thyroid antibodies can be suggestive of diagnosis. Ultrasonography: Both A-scan and B-scan transocular echograms can be used to visualize the orbital structures and determining recti muscle enlargement. Advantage is its low cost, lack of ionizing radiation and relatively short examination time. Laboratory Test
  25. Computed tomography (CT) scan: It demonstrates enlargement of the bellies and sparing of the tendons. It helps in assessing the relationship between the optic nerve and muscles at the apex, which helps in planning for the surgical intervention if needed. Magnetic resonance imaging (MRI): Fusiform rectus enlargement and orbital fat expansion may be identified. MRI may also aide in assessing water content in the muscles and other soft tissues. This may correlate with active inflammation. Imaging Exophthalmos noted in axial view of CT-scan. Patient with TED also demonstrates enlargement of extra ocular muscles (asterisk).
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  27. Orbital pseudotumour Caroticocavernous fistula Inflammatory orbitopathy e.g, granulomatosis with polyangitis Orbital myositis (OM) Orbital tumors IgG4 disease
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  29. The most current grading systems of TED are the VISA classification and the European Group of Graves' Orbitopathy (EUGOGO) classification. The utility of these grading systems is that both assess severity and activity. VISA: V (vision, optic neuropathy) I (inflammation, congestion) S (strabismus, motility restriction) A (appearance, exposure). The 4 severity parameters can be found in the name, and a maximum score of 20 is used to grade the severity of disease. Each of the four parameters has further divisions in order to better asses the activity of the disease
  30. EUGOGO classification attempts to assess both disease activity and disease severity. Activity is based on four measures of inflammation, pain, redness, swelling, and impaired function, and function is graded with decreasing monocular motion and diminishing visual acuity. The classification system also has developed an image atlas which can be used to accurately grade the patient in front of you. Additionally, the EUGOGO grading system does well in differentiating management categories
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  32. Conservative For corneal exposure, lubricants, taping and protective shields can be tried and if necessary tarsorrhapphy can be done. Sleeping with the head of the bed elevated to decrease orbital edema. Both smoking cessation and euthyroid status help preventing further exacerbation and decrease the duration of active disease. For diplopia, Fresnel prisms or occlusion therapy may be considered. Oral NSAIDs may be used for periocular pain. Selenium has shown significant benefit in patients with mild, non‐inflammatory orbitopathy Lifestyle modifications e.g. sodium restriction to reduce water retention and tissue edema.
  33. This biologic infusion therapy has been shown in clinical studies to reduce signs and symptoms of TED. Teprotumumab binds to IGF-1R and blocks its activation and signaling. Tepezza (Teprotumumab-trbw) is the first and only FDA-approved prescription treatment for TED. Teprotumumab
  34. To decrease orbital inflammation oral prednisone in a dose of 1- 1.5- mg/ kg can be given for a suggested maximum period of 2 months. Intravenous (IV) corticosteroids pulse methyl prednisolone can be considered as an alternative. Systemic steroids
  35. Can be used alone or in conjunction with corticosteroids. The radiation therapy works on the similar mechanism of decreasing inflammation. Typical dose of 2000 cGy for each orbit 200 cGy / day given over a period 10 days. It generally improves vertical motility. Radiation retinopathy may occur as a side effect. Orbital Radiation
  36. In cases of significant strabismus, strabismus surgery may be required and should be done with adjustable sutures since the muscles typically do not respond as normal muscles would to strabismus surgery. Strabismus surgery should be considered only after orbital decompression is complete and muscle alignment has stabilized. Strabismus surgery
  37. These reconstructive surgical procedures may be preformed to address eyelid retraction or exposure keratitis. Eyelid Retraction Repair and Tarsorrhaphy
  38. Rituximab is a monoclonal antibody that targets CD‐20 on B‐cells Alternative Treatments
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  40. An ocular emergency, and occurs in <5% of patients with typical TED resulting in slowly progressive fulminant visual loss. It occurs due to compression from the oversized recti and orbital fat causing compartment syndrome at the apex of orbit. It is characterized by decrease in vision, color vision, contrast sensitivity and relative afferent papillary defect. The characteristic visual fields commonly show central, cecocentral, paracentral, and nerve fiber layer bundle defects. Optic nerve head examination can be normal, optic disc edema, or pallor Compressive optic neuropathy
  41. This surgical procedure enlarges the existing space of the orbit by partial removal of bony walls. Orbital decompression commonly involves the orbital floor, medial wall, and lateral wall. In rare cases the roof of the orbit may also be decompressed surgically. Orbital Decompression
  42. CREDITS: This presentation template was created by Slidesgo, including icons by Flaticon, and infographics & images by Freepik THANK YOU Reference: EyeWiki, Thyroid Eye Disease

Notes de l'éditeur

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