3 Graves Orbitopathy Flashcards
TED recap
- clinical orbital signs (lid retraction / proptosis / optic neuropathy)
- laboratory tests (positive bloods for autoantibodies)
- typical orbital imaging finding (swollen EOMs)
Symptoms in the mild stage
Foreign body sensation;
dry eye; excessive tearing; conjunctival or eyelid redness
and swelling;
blurred vision;
retro-orbital pain
Clinical features in mild stage
Mild, soft tissue inflammation;
Dilated conjunctival vasculature;
keratoconjunctivitis
Symtoms in moderate stage
Pulling sensation around the eye; Eyelid redness and swelling; Eyelid retraction and bulging eyes, Swelling of extraocular muscles; chemosis; eyelid oedema; proptosis
Clinical features in moderate stage
Horizontal, vertical, and torsional strabismus with double vision;
deteriorating blurred vision; fading colour vision in one or both eyes; decrease in visual acuity, visual field, and colour vision
(signs of optic neuropathy)
Progressive proptosis with eyelid retraction; corneal ulceration; inflammation of extraocular muscles and scarring leading to strabismus and ophthalmoplegia; increased intraocular pressure
Orthoptists role
- Diagnosis
- Assessment of visual function
- Document effects on ocular muscles
- Record disease progress
- Establish when ocular signs stabilise
- Explanation, information and signposting
- Eliminate symptoms / diplopia
- Plan long term management
Orthoptic investigation
- Assess visual function
- Cover test
- Note any AHP (abnormal head posture)
- OM + measure PA
- BSV tests (inc VPFR)
- PCT + torsion (synoptophore or torsionometer)
- Uniocular field of fixation
- Field of BSV
- ?Lees screen / Hess (not useful in bilateral cases)
Colour vision and TED
As the extra ocular muscle swell and the eye becomes proptosed the optic nerve is affected. This can cause colour vision defects.
Colour vision testing
100 hue, D15, Ishihara, City
Visual function testing- pupils
Checks for optic nerve damage which may occur if ON compression
Clinical signs of ON compression
- Reduced VA
- Reduced CS
- Reduced colour vision
- Visual field defect
- RAPD (Relative Afferent Pupillary Defect)
- Optic disc exam – normal / swelling / pallor
- Optic neuropathy – approx 5%
Modified UFOF
Modified technique for UFOF, Reliable, Rapid, minimising discomfort, Change of 8 degrees is significant
Modified UFOF technique
This modified technique for measuring UFOF gives additional quantified information on the vertical extraocular muscles. Its reliability is equivalent to that of other measurement methods in healthy subjects and in those with restricted motility. It can be performed rapidly, minimizing patient discomfort, and may be particularly helpful in the sequential assessment of GO. The data on patients with GO suggest that a difference of 8° is required to detect significant change, particularly where several observers are involved, and this has important implications for the monitoring of GO, especially when using the CAS.
Differential diagnosis
Acute presentation- Carotid-cavernous Fistula, Myositic pseudotumour Ocular myositis,
Leukemia
Chronic presentation- Metastatic tumours, Lymphoma, Chronic progressive external ophthalmoplegia
Myasthenia- Fatigue, Variable ptosis, Limitation not persisting on FDT
Classification systems
Werner’s classification
Mouritis CAS
EUGOGO
Werners classification system
Werner’s classification (NO SPECS)
Stage Ocular signs and symptoms
1 None
2 Only signs, no symptoms
3 Soft tissue involvement
4 Proptosis
5 Extraocular muscle involvement
6 Corneal involvement
7 Sight loss
0 = absent a = minimal b = moderate c = marked
Mouritis clinical activity store (CAS)
Mourits (1997) Clinical Endocrinology 47:9-14
Clinical activity score (CAS) is based on the clinical signs of inflammation:
* Pain
* Redness
* Swelling
* Impaired Function
◦ Ten items considered
◦ For each item present a point is given
First visit score only 1-7, review visits score 1-10
1. Painful oppressive feeling on or behind the globe in last 4 weeks
2. Pain on eye movement in last 4 weeks
3. Redness of eye lid
4. Diffuse redness on conjunctiva covering at least 1 quad
5. Swelling of lid (erythema)
6. Chemosis
7. Swollen caruncle
8. Increase in proptosis >2mm in 1-3 months
9. Reduced motility 5 degrees
10. Reduction in VA of 1 line with PH over 3 months
Mild: Mourits Activity score 4 Moderate: Mourits Activity 4-6 Severe: Mourits
Activity 7 – 10 or presence of vision threatening signs (Exposure, optic nerve oedema, or RAPD
EUGOGO – European Group on Grave’s Orbitopathy
Combines CAS with measures of severity
1. Spontaneous retrobulbar pain
2. Pain on up or downgaze
3. Redness of eye lid
4. Redness on conjunctiva
5. Swelling of lid (erythema)
6. Inflammation of the caruncle
7. Conjunctival oedema
3 or more = active GO
