2. Introduction
• TED also k/a thyroid associated orbitopathy and Graves
ophthalmopathy is a very common orbital disorder.
• MC cause of both unilateral and bilateral proptosis in an
adult
• Multifactorial , idiopathic Auto-immune disease
• Excessive secretion of thyroid hormones
• Mostly associated with:
– Graves hyperthyroidism
– Hashimoto thyroiditis
– Euthyroidism
3. Epidemiology
• About 42 million people in india suffer from thyroid disease.
Prevalence is >12% in U.S. population
• TED is newly diagnosed at rate of abt 2.9 men and 16 women
per 1 lac people/ year
• Smokers 7x
• 30-50 Years- age group
• Associated with:
– 90% Graves hyperthyroidism
– 6% Euthyroidism
– 3% Hashimoto thyroiditis
– 1% Primary hypothyroidism
• Onset:
– 20% of TED is diagnosed same time as hyperthyroidism
– 60% of eye disease occur 1 year after thyroid disease
– Only 30% of hyperthyroidism TED
4. Pathology
Activated T cells infiltrate orbital contents
and stimulate fibroblasts, leading to:
1.Enlargement of extraocular muscles
2.Cellular infiltration of interstitial tissues
3.Proliferation of orbital fat and connective
tissue
6. Cellular infiltration of interstitial tissues
• Lymphocytes, plasma
cells, macrophages and
mast cells infiltrate
extraocular muscles, fat
and connective tissue
Lymphocyte cuff
7. Pathololgy (cont’d)
• Causes degeneration of
muscle fibres
• Leads to fibrosis of the
involved muscle
Build up of fibrous
tissue
8. Systemic features
• GENERAL- fatique, goitre, heat intolerance, increased
GI motility, muscle weakness, wt. loss with
increased appetite
• PSYCHOLOGICAL- anxiety, depression, irritability,
nervousness
• CVS- atrial fibrillation, palpitation, systolic ejection
murmur
• DERMATOLOGICAL- smooth skin, sweating, warm
and moist skin
• NEUROMUSCULAR- hyperreflective DTR, tremor
9. Ocular Features
• Symptoms:
– Grittiness
– Photophobia
– Lacrimation
– Retrobulbar discomfort
• Signs:
– Soft tissue involvement
– Lid retraction/ lid lag
– Restrictive EOM movement
– Proptosis
– Optic neuropathy
– Exposure keratopathy
• 2 Stages:
– Congestive: remits within 3 years, 10% long term problems
– Fibrotic: restrictive movement
10. Lid Retraction
• 50%
• Fibrotic contracture of levator:
– Worsening of lid retraction in downgaze
• 3 signs:
Dalrymple Sign Kocher Sign Von Graefe Sign
• 50%
• Fibrotic contracture of levator:
– Worsening of lid retraction in downgaze
• 3 signs:
12. Restrictive EOM
• 30-50%
• Inflammation of EOM
– cells infiltration retain fluid swelling compression
– Muscle fibers degeneration fibrosis
• Elevation defect: IR fibrosis (fibosis IR MR SR LR SO/IO)
• Abduction defect: MR fibrosis
• Depression defect: SR fibrosis
• Adduction defect: LR fibrosis
Elevation defect of left eye Depression defect of right eye
13. ON Compression
• Uncommon (5%) but serious
• Inflammation of EOM cells infiltration GAG fluid retention
orbital pressure compression
• +/- proptosis
• Signs:
– Reduced VA, +/- RAPD, color desaturation
– VF defect: central or paracentral, increased IOP (confused with POAG)
– Optic Disc may be normal / swollen and rarely atrophic
Enlargement of recti with tendon sparing
15. Severity of TED –WERNER’S
CLASSIFICATION (NO SPECS)
• Class 0: No signs or symptoms
• Class 1: Onlysigns (lid retraction, stare ±lid
lag)
• Class 2: Soft tissue involvement
• Class 3: Proptosis
• Class4: Extraocular muscle involvement
• Class5: Corneal involvement
• Class6: Sight loss (optic nerve involvement)
16. EUGOGO Classification of TED
Severity- commonly used now
• Sight-threatening
– Optic neuropathy
– Corneal breakdown
• Moderate-Severe
– Lid retraction (≥2mm), moderate-severe soft
tissue involvement, proptosis (≥3mm),
diplopia
• Mild- with only a minor impact on daily life
17. Screening test for Graves
orbitopathy
• Thyroid profile should be done all patients of
age group 30-50 yrs. Preferably in all females
• TSH – very low (normal 0.3-5.5 )
• Free T3 – elevated ( normal 60-200)
• Free T4 – elevated (normal 4.5-12)
18. Diagnosis
• 2 of 3 sign present
– Thyroid dysfunction:
• Grave
• Hashimoto
• Thyroid Ab, TSH-R, TBII, TSI, antimicrosomal
– Orbital sign as above
– Evidence of uni/bilateral fusiform enlargement of 1
or more EOM
• IR
• MR
• SR/ elevator complex
• If only 1 orbital sign; observe
19. Prognosis
– self-limiting disease average lasts 1 year
– 2-3 years in smoker, 7x develop the orbital S/S
– Reactivation 5-10%
– Poor prognostic features include:
• smoking
• rapidly progressive orbitopathy
• dermopathy
– Most patient require only support care
– Intervention may be necessary if inflammation is
severe
– long-term F/U- based on severity of pt. s/s. Some
may require FU once a month while others every 2
weeks
20. Management
• Supportive care-
• Corticosteroids - oral , intravenous
• Orbital radiation treatment -
• Surgery-
- orbital decompression
- strabismus surgery
- eyelid surgery
21. Treatment based on EUGOGO
classification of TED severity
• MILD DISEASE-
– Stop smoking
– Lubricants for SLK, corneal exposure,
dryness
– Topical anti-inflammatory agents- steroids,
NSAIDS, cyclosporin
– head elevation with 3 pillows during sleep to
reduce periorbital edema
– Eyelid taping during sleep to alleviate mild
exposure keratopathy
22. Treatment
• MODERATE TO SEVERE ACTIVE DISEASE-
– Systemic steroids are the main stay of t/t
– Oral prednisolone 60-80mg/day given initially
and tapered a/c response.
– i.v. methylprednisolone 0.5g -1g/day for 3days is
often reserved for acute compressive ON
– Orbital steroid injections used in selected cases
– Low dose fractionated radiotherapy may be
used in addition to steroids or when steroids are
C/I
23. Moderate to severe active ds t/t
• Orbital wall decompression or orbital apex
decompression are considered if steroids
are ineffective or C/I
• Several drugs targeting specific aspects of
immune response in TED are under
investigation like monoclonal ab, Rituximab
24. Radiation therapy
-- induce terminal differentiation of fibroblast
– kill tissue-bound monocyte
– Should avoid in: diabetes and vasculitis as
may exacerbate retinopathy.
– Combined therapy with irradiation ,
azathioprine and low-dose prednisolone
may be more effective than steroids or
radiotherapy alone
25. Complications of orbital radiation
• Cataract
• Radiation Retinopathy
• Optic neuropathy
• Increased risk of local cancer
26. T/t of post-inflammatory
complications (Surgery)
• Orbital decompression- for proptosis
• Strabismus surgery- for restrictive
myopathy
• Eyelid surgery- for lid retraction
27. Proptosis
• Orbital decompression- surgical decompression
increases the volume of orbit by removing
bony wall or may be combined with
removal of orbital fat.
• 1 wall(lat)- 4-5mm reduction
• 2 walls- 5-7mm reduction
• 3 walls- 6-10mm reduction
• All 4 walls- 15mm reduction
29. Complications of orbital
decompression
• Diplopia
• Medial lower eyelid entropion
• Retrobulbar hemorrhage
• Vision loss
• Hypesthesia in distribution of infraorbital
nerve
• Sinusitis, Nasolacrimal duct obstruction
• Cerebrospinal fluid leak
• Frontal lobe hematoma
30. Restrictive myopathy
• Strabismus surgery- angle of deviation
stable for at least 6-12 months
• Diplopia alleviated with prism or
botulinum toxin
• Aim is to achieve binocular single vision in
primary and reading position
• most frequent is recession MR or IR (6-
7mm)
32. Lid retraction
• Mild lid retraction improves
spontaneously
• Control of hyperthyroidism
• Botulinum toxin injections to levator
aponeurosis and muller muscle
• Mullerectomy for mild lid retraction
• Recession / disinsertion of levator
aponeurosis in severe cases
34. Surgical follow up
• Routinely followed up at -
• 1 day
• 1 week
• 1 month, 2 months, 3 months 6 months, 9
months
• 1 year
35. Message home
– Eyelid retraction is the most common feature of
TED
– TED is the most commonly a/s uni/bilateral
proptosis, markedly asymmetric
– 90% hyper, but 6% euthyroid
– Severity is not parallel to serum level (TSH, T3,
T4..), but the smoking indeed 7x
– Urgent care may be require for CON, severe
proptosis cornea decompensation
– Surgery should be in order: Orbital decompression
Strabismus eyelid correction
