Occular manifestations of thyroid disorder

1. Thyroid Diseases
Ocular Manifestations
JeevanShrestha
Presented by: Jeevan Shrestha
KMCTH

2.  I have no conflict of interest or disclosure in relation to
this presentation.

3. Thyroid Disorders
 Grave’s Disease
 Hashimoto's Thyroiditis
 Thyroid Carcinoma
 Primary Hyperthyroidism
 Neck Irradiation
JeevanShrestha

4. Grave’s Ophthalmopathy
 Is an autoimmune inflammatory disorder affecting the orbit
around the eye, characterized by upper eyelid retraction, lid lag,
swelling, redness, conjunctivitis, and bulging eyes.
 Various Names:
 Thyroid Eye Disease(TED)
 Thyroid-associated Ophthalmopathy (TAO)
 Dysthyroid Ophthalmopathy
 Thyroid Orbitopathy
 Endocrine Ophthalmopathy

5.  Sex: More common in female than male 4:1
 Smoking
 Middle age
 Autoimmune thyroid disease
 HLA-DR3 and HLA-B8
 TED associated with Hyperthyroidism(90%), Hypothyroidism(4%),
Euthyroidism(6%)
Risk factors

6. Onset
 20% of TED is diagnosed same time as hyperthyroidism
 60% of eye disease occur after 1 year of thyroid disease
 Only 30% of hyperthyroidism  TED

7. Pathogenesis
 Inflammatory targets:
 Primary: Orbital fibroblast
 Secondary: Extraocular muscles
 Activated T-cells act and stimulate
adipogenesis, fibroblast proliferation
and glycosaminoglycan synthesis.
 Enlargement of extraocular muscles
due to edema and infiltration
 Orbital soft tissue infiltrated with
lymphocytes, macrophages and mast
cells

8. Pathogenesis
 Autoimmune disorder(IgG mediated)
 Enlargement of Extraocular Muscles
- By Increase in Glycosaminoglycans
 Cellular Infiltration of Interstitial Tissues
- With lymohocytes, plasma cells and macrophages, mast cell
- Fibrosis
 Proliferation of Orbital fat, Connective tissue and Lacrimal Gland
- With retention of fluid and GAG

9. Grave’s Ophthalmopathy
Axial CT
Extraocular Muscle Enlargement
(Fusiform Appearance)

10. Clinical Features
 LID SIGNS
- Retraction of Upper Lids
(Dalrymple’s Sign) in 90%
- Lid Lag in 50% (von Graefe’s Sign)
- Fullness of Eyelids(Enroth’s sign)
- Difficulty in Eversion of Upper Lid
(Gifford’s Sign)
- Infrequent Blinking( Stellwag’s Sign)

11. Clinical Features
 Conjunctival Signs:
- Deep Injection and Chemosis
 Pupillary Signs:
- Unequal dilated pupils
 Occular Motility Defects:
- - Mobius’s sign
 Exophthalmos (60%)
 Exposure Keratitis and ocular
discomfort
 Optic Neuropathy

12. Classification
- By American Thyroid Association(ATA)
 Class 0: N : No signs and symptoms
 Class 1: O : Only signs( Lid retraction with/without lid lag & proptosis)
 Class 2: S : Soft tissue involvement with signs in class-1 and symptoms like
. Lacrimation,photophobia, lid or conjunctival swelling
 Class 3: P : Proptosis well established
 Class 4: E : Extraocular muscle movement limited and diplopia
 Class 5 : C : Corneal involvement( Exposure Keratitis)
 Class 6: S : Sight loss (Optic nerve involvement and visual field defects)

13. Rundle’s Curve
a - Mild Opthalmopathy
b – Ocular
discomfort . . &
eyelid disfunction
c- Active Diplopia
d- Optic Nerve.
dysfunction

14. Diagnosis
 Grave’s Ophthalmopathy:
 10-20% Precede hyperthyroid
 40% Concurrent
 30% < 6 months after diagnosis
 10-20% > 6 moths after Dx

15. Investigations
 Thyroid Function Tests:
- Serum T3,T4,TSH
 Positional Tonometry:
 Ultrasonography:
- Changes in extraocular muscles
 Computerised tonographic scanning:
- Show proptosis, Muscle thickness, Optic Nerve thickening
 MRI(T2- weighed and STIR):
 Orthoptic workup:

16. Treatment
A) Non- surgical Management:
- Smoking Cessation
- Head elevation at night & cold compressors in morning(Reduce periorbital
edema)
- Lubricating artificial tear drops
- Eyelid taping
- Guanethidine 5% eyedrop ( Decrease lid retraction)
- Prisms
- Systemic steroids
- Radiotherapy
- Combined therapy : ( Low dose steroids + Azathioprine + Irradiation)

17. Treatment
(B) Surgical Management:
i)Orbital Decompression:
- Two wall Decompression (Orbital floor and medial wall removed)
- Three wall Decompression (Floor, medial and lateral wall removed)
- Four wall Decompression ( Three wall removal plus lateral half of roof and. .
. large portion of
sphenoid at apex)
ii) Extraocular muscle surgery:
- Always done after orbital decompression
- To achieve binocular single vision in reading position

18. Treatment
iii) Eyelid Surgery :
- Mullerotomy
- Levator recession/disinsertion
- Scleral grafts
- Recession of lower eyelid retractors
- Blepheroplasty

21.  Dalrymple’s sign: Lid retraction
 • von Graefe’s sign: Upper lid lag on downward
Gaze
 • Kocher’s sign: Increased lid retraction with visual fixation

22.  • Ballet’s sign: Palsy of one or more extraocular muscles
 • Suker’s sign:Weakness of fixation on lateral gaze
 • Cowen’s sign: Jerky papillary contraction to consensual light
 • Knies’ sign: Unequal dilatation of the pupils
 • Jeffrey’s sign: Absence of forehead wrinkling on upward gaze
 Griffith’s sign: Lower lid lag on downward gaze
 • Stellwag’s sign: Infrequent blinking
 • Enroth’s sign: Puffy swelling of the lids
 • Mobius’ sign:Weakness of convergence
mobius

23. THANK YOU
Marty
Feldman
Presented By :
Jeevan Shrestha