Graves orbitoptathy Flashcards

Question

what lid symptoms do people with graves have

Answer 1

upper lid , lower lid and palpebral appeture lid retraction

Answer 2

Position patient’s head correctly Ask patient to fixate on target positioned at their eye level and in the distance. Ask patient to relax as much as possible to record the minimum amount of retraction for that patient (i.e. Müller’s muscle as relaxed as possible). Observer holds vertical clear plastic ruler near to visual axis without touching eyelashes Observer should consistently use only one of their eyes, and on same horizontal level as patient’s eye. For patients with manifest strabismus, the contralateral visual axis is occluded prior to measurement. Record in mm

Answer 3

hertel mirrpor exopthalmoeter

Answer 4

12-21 12-33 12-20 12-24

Answer 5

Bilateral Asymmetric Unilateral ? Normal exophthalmometry >22mm or asymmetry greater than 3mm Amount depends on severity of disease/ inflammation and structure of anterior orbital septum Axial / non-axial

Answer 6

Wet phase – Active phase Cellular infiltration with glycosaminoglycans (GAGs) and osmotic inhibition of water This leads to EOMs becoming up to 8-10x enlarged May compress ON leading to visual loss Subsequent degeneration of muscle fibres leads to fibrosis resulting in restriced motility and diplopia This phase tends to settle within 3 years

Answer 7

Fibrotic Phase / Dry Phase Muscle fibres become distorted, contracted and damaged due to fibrosis Eyes are white and quiet Painless, restrictive myopathy may be present

Answer 8

enlarged by 10 times muscle but not tendon

Answer 9

Limitation Reversal Saccades Cog wheel pursuit Fatigue Pain Retraction Bilateral involvement

Answer 10

IR MR SR, LR SO, IO (Thacker et al 2005) Vertical, horizontal and torsional diplopia Swelling of EOM results in restriction: if IR affected then pt unable to elevate as eye becomes tethered down

Answer 11

mri scans can aid diagnosis

Answer 12

GO is an autoimmune condition diagnosed by blood tests along with clinical history and assessment

Answer 13

Patients are usually hyperthyroid, but can be hypothyroid or euthyroid

Answer 14

Upgaze typically affected first Multiple distinctive eye signs Can result in painful eye movements, diplopia or visual loss

Answer 15

because of inferior rectus enlargement

Answer 16

TED can be diagnosed when two of the following three signs are present: clinical orbital signs (lid retraction / proptosis / optic neuropathy) laboratory tests (positive bloods for autoantibodies) typical orbital imaging finding (swollen EOMs)

Answer 17

symptons Foreign body sensation; dry eye; excessive tearing; conjunctival or eyelid redness and swelling; blurred vision; retro-orbital pain signs Mild, soft tissue inflammation; Dilated conjunctival vasculature; keratoconjunctivitis; corneal staining

Answer 18

pulling sensation around the eye eyelid redness and welling , eyelid retraction and bulging in the eyes swelling of eom chemises eyelid oedema proptosis

Answer 19

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;

Answer 20

Diagnosis Assessment of visual function Document effects on ocular muscles Record disease progress Establish when ocular signs stabilise Explanation and information and signposting Eliminate symptoms / diplopia Plan long term management §

Answer 21

Assess visual function CT Note any AHP 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)

Answer 22

contrast sensitivity visual fields pupils

Answer 23

on compression = ocular emergency reduced va reduced cs reduced colour vision visual field defect rapid - relative afferent pupillary defect optic disc exam - normal/ serving / pallor optic neuropathy - approx 5%

Answer 24

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.

Answer 25

Acute presentation Carotid-cavernous Fistula Myositic pseudotumour Ocular myositis Leukemia see Pai et al 2011 for case study Chronic presentation Metastatic tumours Lymphoma Chronic progressive external ophthalmoplegia Myasthenia Fatigue Variable ptosis Limitation not persisting on FDT

Answer 26

1 None 2 Only signs, no symptoms 3 Soft tissue involvement 4 Proptosis 5 Extraocular muscle involvement 6 Corneal involvement 7 Sight loss

Answer 27

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

Answer 28

sight threatening graves - patients with dysthyroid optic neuropathy and corneal breakdown moderate to sever go - patients without sight threatening go whose eye disease has sufficient impact on daily life to justify the risks of immunosuppression or surgical intervention - patients with moderate or sever soft tissue involvement usually have one of the following lid retraction exothalmos mild go - patients with mild have a minor impact - insuffiecnt for surgery , minor lid retraction/exopthalmos or soft tissue involevemt, corneal exposure responsive to lubricants

Answer 29

Orthoptic / conservative Surgical: Sight saving Strabismus Lid

Answer 30

Preserve visual function Keep patient comfortable and symptom free Allow comfortable BSV in pp and reading position where possible

Answer 31

Encourage use of AHP Prisms - temporary / incorporated Occlusion – blenderm / patch / frosted lens Surgery BT

Answer 32

Non urgently “Gritty” sensation and/or eyes sensitive to light Progressive change in eye appearance Pain in or behind the eyes Diplopia Eyelid retraction Swelling/redness of eyelids and/or conjunctiva Restriction of eye movement Tilting of head to avoid double vision

Answer 33

Urgently Sudden deterioration in vision Problems with colour vision Sudden onset proptosis Failure of full eye closure Corneal opacity Abnormal disc possible described on referral optometrist/eye casualty

Answer 34

ON compression – orbital surgery 2. Strabismus / ocular realignment surgery 3. Lid surgery Multidisciplinary approach: May involve maxillary facial surgeons, strabismologist and orbital surgeons

Answer 35

Orbital changes Retrobulbar adipose tissue is increased in volume and may have lymphocytic infiltrate. Increased volume of orbital contents typically leads to exophthalmos May lead to ON compression / neuropathy

Answer 36

steroids radiation orbital decompression

Answer 37

Mechanisms anti-inflammatory immune response - immunosuppressive decrease mucopolysaccharide production by orbital fibroblasts Indications acute inflammatory disease optic neuropathy - mild VA loss recent onset <6m, predominantly severe soft tissue signs following other treatments pre / post decompression

Answer 38

Another immunosuppressant Allows reduction of steroid if prolonged large doses – reduces side effects of steroids Effects modest

Answer 39

Well tolerated no short term side affects usually no long term side affects Reduces symptoms but not the course of the disease Referral to oncologist face mask to immobilise patient and allow accurate delivery of radiation planning with CT 2 weeks of treatment delivered daily 50 centres, ? priority

Answer 40

reduce the cells which cause the inflammation and so reduce the swelling behind the eye. It may take up to a year to notice the full effect. ten radiotherapy treatments given over two weeks face mask to immobilise patient and allow accurate delivery of radiation Risk of cataract Risk of dry eyes

Answer 41

Daily doses of radiation beams directed at the orbital area Low dose of 2Gy x ten days Destroys lymphocytes and fibroblasts reducing auto-immune response First weeks often in conjunction with steroids Increased chemosis in first week of treatment Improvement after 2 weeks of treatment If no improvement in 1 month of treatment unlikely to improve

Answer 42

Indicated in patients with severe acute soft tissue signs - (steroids initially as radiotherapy not immediate) recent onset progressive proptosis acute ophthalmoplegia acute vision loss where steroid treatment has failed

Answer 43

Mourits 1997 Success of radiotherapy treatment Patients with CAS > 4 = 80% chance of improvement Patients with CAS < 4 = 36% chance of improvement

Answer 44

Mourits 1997 Success of radiotherapy treatment Patients with CAS > 4 = 80% chance of improvement Patients with CAS < 4 = 36% chance of improvement

Answer 45

an operation to remove bone from the walls of the orbit (the eye socket) in order to reduce the amount of protrusion of the eye Indications sight threatening situations Improve cosmesis (40%, Lyons & Rootman 1994)

Answer 46

Lateral 2. Transantral 3. Transfrontal 4. Ethmoidal 5. Maxillary

Answer 47

lateral orbital (single) for moderated orbital fat decompression alone for mild proptosis

Answer 48

Temporary lip numbness Asymmetric correction of proptosis Sinusitis* Apparent  upper lid retraction Orbital cellulitis* Late endophthalmos Meningitis* Epiphora Lower lid entropian Diplopia Blindness 1/10000 * 10/7 antibiotics

Answer 49

No advantage in having early rehabilitative decompression for aesthetics Associated with higher risk of diplopia

Answer 50

Occurs in 15-51% of patients with TED Diplopia which impacts on work / driving / ability to function independently Vertical

Answer 51

Medical condition stable Eye condition stable Problematic diplopia Uncomfortable head posture Centralise and / or enlarge field of BSV

Answer 52

Extraocular Muscle Surgery Forced duction testing - pre, intra and post op Recession of muscles, avoid resections Free adhesions Undercorrection Adjustable sutures – allow fine tuning and adjustment of AHP Inferior rectus dissected from attachments to lower lid Inferior rectus recession Medial rectus recessions

Answer 53

Six months stability” In practice tend to wait longer until sure disease has stabilised

Answer 54

Lid retraction (upper and lower lid) Levator palpebral superioris - muscle fibre enlargement and oedema - rarely affects function Overaction of Muller’s muscle (sympathetic overaction) Innervation to SR and levator palpebral superioris

Answer 55

Guanethidine Topical (drops) alpha-adrenergic blocking agent Triamcinolone - oral anti-inflammatory / anti- fibrotic effect

Answer 56

Levator muscle procedures Müller’s muscle procedures Combination of above Aim to leave ptotic - gradually elevates Lateral tarsorrhaphy rarely used now not very effective may prevent exophthalmos

Answer 57

Levator muscle procedures recession tenotomy BT - Ozkan et al, 1997 4 patients (8 eyes) effective for 3-4 months Noah & Eckstein (2007) 5-15 IU BT to levator or Mullers muscle Transient diplopia or ptosis in up to 20% cases

Answer 58

Lid retraction – Henderson’s operationWeakening of Müller’s muscle

Answer 59

Blepharoplasty (surgical correction of a lid deformity) mark out excess skin excise skin and orbicularis remove fat Complications Infection Bleeding Dry / irritated eyes Difficulty closing eyelids

Answer 60

Tape lids Glasses with side protection hypromellose Steroids Orbital decompression Tarsorraphy

Answer 61

Rituximab is a drug which depletes B cells promoting antibody-dependent cellular toxicity It was used initially to treat non-Hodgkin B-cell lymphoma and more recently has benefited individuals with rheumatoid arthritis. Sustained resolution of Optic neuropathy & inflamation But proptosis and strabismus were unimproved by RTX no sufficient evidence to support its effectiveness

Answer 62

New medicine to treat GO Human monoclonal antibody Approved for use in USA in Jan 2020 Expensive - $343000 per patient for 6 months of treatment (approx. £250k) only medication that reduces the fat and muscle expansion within the orbit Only medicine to possibly reduce ON compression Some patients remain non-responders to treatment Possible side effects: hearing loss, hyperglycemia, and muscle spasm