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Thyroid associated orbitopathy of dr. sohel mahmud
1. Thyroid associated orbitopathy
Presentation is made by
Dr. Sohel Mahmud
MBBS, DO.
Eye specialist & surgeon
Dhaka, Bangladesh.
A stone made statue of a
man with unilateral
proptosis at the time of
ancient Greece.
3. Introduction cont...
Thyroid-associated orbitopathy (TAO) is
an autoimmune inflammatory disorder that
can affect the orbital and periorbital tissue,
the thyroid gland and rarely the pretibial
skin or digits.
4. Epidemiology TAO
• Commonly presents during fourth and fifth decades
• Median age at the time of diagnosis 43years
• Range 8-88years
5. Epidemiology of TAO cont...
86%
Women
14%
Men TAO affects women approximately 6 times
more frequently than men.
Smokers are up to 7 times more likely
than nonsmokers to develop TED. 89%
Smokers
11%
Nonsmokers
6. Etiology
• TAO typically associated with Graves’ hyperthyroidism but
may also occur with Hashimoto’s thyroiditis or in absence of
thyroid dysfunction
7. Pathogenesis
CD1
54
Orbital
fibrobla
st
T
cell
Up-regulation –
1. IL-6
2. IL-8
3. PGE2
Synthesis of-
Hyaluronan
GAG is
increased
Derived from
neural crest and
possess
developmental
plasticity
1
A subpopulation
undergoing adipocyte
differentiation causing fatty
hypertrophy particularly in
those younger than 40
2
Up-regulation of
TSH-R mRNA
synthesis
Adipogenesis-
Expansion of
orbital fat
compartment
3
Circulating IgG
activates insulin like
growth factor
Found
in a
majority
with
Graves
disease
4
8. Histopathology
Findings on histological examination-
• Fibrosis with degenerative changes in the eye
muscles
• Lymphocytic cell infiltration
• Enlargement of fibroblasts
• Accumulation of mucopolysaccharides
• Interstitial edema
• Increased collagen production
13. Mechanism of lid retraction
•Fibrotic contracture of the levator
•Secondary overaction of the levator superior
rectus complex
•Humorally induced overaction of muller muscles
Courtesy by oculoplasty dept. of
NIO&H
14. Proptosis
• Axial
• Uni/bilateral
• Symmetrical/ asymmetrical
Severe proptosis leads
to -
•Exposure keratopathy
•Corneal ulcer
•Infection
Courtesy by oculoplasty dept. of
NIO&H
15. Restrictive myopathy
• Initially by inflammatory edema later for fibrosis
•Elevation defect
•Abduction defect
•Depression defect
•Adduction defect
Courtesy by oculoplasty dept. of
NIO&H
16. Optic neuropathy
• Uncommon but serious complication
• Caused by compression of the optic nerve or its
blood supply at the orbital apex
23. Courtesy by oculoplasty dept. of
NIO&H
•Fusiform enlargement of muscle
•Tendon spearing
•Muscle border smooth
On CT scan of orbit and brain-
Investigation cont…
24. Diagnostic criteria
The diagnosis of TAO is made when 2 of the following 3 signs of
the disease are present:
1. Concurrent or recently treated immune-related thyroid
dysfunction (l or more of the following):
a. Graves hyperthyroidism
b. Hashimoto thyroiditis
c. Presence of circulating thyroid antibodies without a
coexisting dysthyroid state (partial consideration given):
TSH-receptor (TSH-R) antibodies, thyroid-binding
inhibitory immunoglobulins (TBll), thyroid-stimulating
immuno-globulins (TSI), antimicrosomal antibody.
25. The diagnosis of TAO is made when 2 of the following 3 signs of
the disease are present:
2. Typical orbital signs (l or more of the following):
a. Unilateral or bilateral eyelid retraction with typical
temporal flare (with or without lagophthalmos)
b. Unilateral or bilateral proptosis (as evidenced by
comparison with
patient's old photos)
c. Restrictive strabismus in a typical pattern
d. Compressive optic neuropathy
e. Fluctuating eyelid edema/erythema
f. Chemosis/caruncular edema
Diagnostic criteria cont…
26. The diagnosis of TAO is made when 2 of the following 3 signs of
the disease are present :
If only orbital signs are present the patient should continue to
be observed for other orbital diseases and for the future
development of a dysthyroid state
3. Radiographic evidence of TAO- unilateral/bilateral
fusiform enlargement
of 1 or more of the following :
a. Inferior rectus muscle
b. Medial rectus muscle
c. Superior rectus/levator complex
d. Lateral rectus muscle
Diagnostic criteria cont…
28. Treatment of TAO cont…
1. Smoking
cessation
2. Lubricating eye
drops
3. Cool compression
4. Salt restriction
5. Elevation of head
6. Wearing sunglass
29. Treatment of TAO cont…
1. Systemic corticosteroids
•Starting dose 60-100 mg orally
•Short-term pulse intravenous dose 1gm daily
several
times a weak for up to 2 months
2. Others
• Cyclosporine
• Ticlopidine
• Intravenous immune globulin
• Somatostatin analogues
30. Treatment of TAO cont…
• Orbital irradiation is prescribed for moderate to severe
inflammatory
symptoms, diplopia and visual loss in patients with TAO
• Typical dose 2000 rad to each orbit, delivered as 200
rad/day for
10 days
31. Treatment of TAO cont…
1. Orbital
decompression
2. Strabismus surgery
3. Eyelid surgery
32. Treatment of TAO cont…
• Observation
• Patient education/lifestyle
changes
• Smoking cessation
• Salt restriction
• Elevation of head of bed
• Wearing sunglasses
• Ocular surface lubrication
• Topical cyclosporine
• Eyelid taping at night
• Moisture goggles/chambers
• Prism glasses or selective ocular
patching
• Moderate-dose oral steroid therapy
• High-dose oral steroid therapy
• Intravenous steroid therapy
• Surgical orbital decompression
• Strabismus surgery
• Eyelid surgery
• Periocular radiotherapy
Refractory disease
• Steroid-sparing immunomodulators
(rituximab)
Mild
diseas
e
Moder
ate
diseaseSevere
disease
33. Prognosis
• TAO is a self-limiting disease
• On average lasts 1 year in nonsmokers and between 2 and 3
years in smokers
• After the active disease plateaus, a quiescent burnt-out phase
ensues
• Reactivation of inflammation occurs in approximately 5%-
10% of patients over their lifetime
Poor prognostic features-
• Smoking
• Rapidly progressive (typically
congestive) TAO
• Presence of myxoedema
