thyroid ophthalmopathy for print
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thyroidTRANSCRIPT
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Grave’s Ophthalmopathy(GO)
Parima Hirunwiwatkul, MD
Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University
Clinical presentation &
Medical treatment
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Clinical presentation
• Dryness and irritation
• Inflammation and pain
• Visual disturbance– Afferent: Decrease acuity, dimming, scotoma, color change
– Efferent : double vision
• Cosmetic
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Eye involvement in GO
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Treatment of TRO
• Avoid risk factors• Symptomatic treatment– Lubricant – Anti‐inflammation : steroids
• Medical treatment– Systemic steroids– Immunosuppressive– Botulinum toxin
• Surgical treatment
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Lubricants
• Artificial tears:– Preservative artificial tear
– Disappeared preservative
– Non preservative/ preservative free
• Form:– Eye drop: bottle, tube
– Eye gel
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No symptoms or signs
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Only signs, no symptoms
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Soft tissue involvement
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Proptosis
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Extraocular muscle involvement
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Corneal involvement
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Sight loss
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*This paper is also being published in the March 2008 issue of the journal, European Journal of Endocrinology, vol. 158, no. 3.
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Recommendations
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Management issues of GO that should be addressed by
both nonspecialists and specialists
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Referral to combined thyroid‐eye clinics and initial assessment
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Refer urgently
• Symptoms– Unexplained deterioration in vision– Awareness of change in intensity or quality of colourvision in one or both eyes
– History of eye(s) suddenly ‘popping out’(Globe subluxation)
• Signs– Obvious corneal opacity– Cornea still visible when the eyelids are closed– Disc swelling
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Refer urgently
• Compressive optic neuropathy (Dysthyroidoptic neuropathy)
• Exposure keratopathy … corneal melting …corneal perforation
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Refer non‐urgently • Symptoms
– Eyes abnormally sensitive to light: troublesome or deteriorating over the past 1–2 months
– Eyes excessively gritty and not improving after 1 week of topical lubricants
– Pain in or behind the eyes: troublesome or deteriorating over the past 1–2 months
– Progressive change in appearance of the eyes and/or eyelids over the past 1–2 months
– Appearance of the eyes has changed causing concern to the patient– Seeing two separate images when there should only be one
• Signs– Troublesome eyelid retraction– Abnormal swelling or redness of eyelid(s) or conjunctiva– Restriction of eye movements or manifest strabismus– Tilting of the head to avoid double vision
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Smoking and GO
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Management of hyperthyroidism in patients with GO
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Management of hyperthyroidism in patients with GO
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Other simple measures that may alleviate symptoms
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Management issues of GO that should be addressedin specialists centers
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Grading severity and activity of GO
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Severity measures• Lid aperture
– distance between the lid margins in mm with the patient looking in the primary position, sitting relaxed and with distant fixation
• Swelling of the eyelids• Redness of the eyelids • Redness of the conjunctiva• Conjunctival oedema• Inflammation of the caruncle or plica• Exophthalmos
– using the same Hertel exophthalmometer
• Subjective diplopia score– 0=no diplopia; 1=intermittent, 2=inconstant, 3=constant
• Eye muscle involvement – ductions in degrees
• Corneal involvement (absent/punctate keratopathy/ulcer)• Optic nerve involvement
– best corrected visual acuity, color vision, optic disc, RAPD (absent/present), plus visual fields if optic nerve compression is suspected
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Grading severity and activity of GO
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Grading severity and activity of GO
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Grading severity and activity of GO
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Management of mild GO
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Management of mild GO
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Management of mild GO
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Take home message Early detection and referral to
ophthalmologist