management of TED Flashcards
CAS AND EUGOGO ACTIVITY SCORING
- Grading the activity of GO is essential before commencing treatment
- Clinical Activity Score CAS (Mourits et al 1997) CAS score of >=4 Active disease requiring treatment
- NOSPECS (Werner 1977) treatment indicated in the severe and moderate to severe groups.
- Vision, Inflammation, Strabismus, Appearance
- Maximum score of 20 with Vision 1, Inflammation 10, Strab 6 (Dip 3, Restriction 3), Appearance 3
EUGOGO
* Modified CAS score out of 10
* Both VISA and EUGOGO provide a diagnostic classification and assessment with practical implications.
They are not interchangeable however
smoking cessation
- The strongest risk factor for severe TED is smoking
- The mechanisms are unclear.
Studies have shown that smokers have a dose dependant relationship between smoking and disease severity and poorer treatment outcomes. (Thornton et al 2007)
Treatment Plans for graves
- Individually designed for each patient
- Restoration of Euthyroidism - carried out by endocrinology
- Care should be taken using radioactive iodine (obliterates thyroid, doesn’t allow hormone to be produced) as it can increase the disease activity.
Profilactic steroids may be helpful. - Better outcome with Thyroidectomy that RAI
Conservative therapy
- In mild cases lubricants may be all that is required.
- Sleeping with an elevated head position - if lying flat the oedema gathers and eyes/ muscles are swollen due to water gathering, elevated head posture allows water to flow
- Taping eyelids
- In severe exposure keratitis, botox could be considered
- Selenium 100ug twice daily can reduce ocular involvement in mild cases Marcocci et al 2011 - useful supplement which improves symptoms in very mild cases
Prisms
- Aim to alleviate diplopia and restore a useful field of BSV - main problem is vertical in early stages as Inferior rectus is affected first
- Usually low strength of prism with increased horiz/vert fusion range - THYROID PX WILL ALWAYS HAVE INCREASED VERTICAL FUSION RANGE
- Patients usually have glasses making fresnel prisms an easy application - can incorporate up to 10^
Botox
Block to neurotransmission, wears off
- Useful for upper lid lowering in severe keratitis
- In early stages of active disease Lyons et all (1990) found it useful, when diplopia couldn’t be relieved with prisms. Not commonly used
Occlusion
- In the unlikely event that prisms can’t be used to regain BSV.
- Sector occlusion can be useful for lateral gaze - only put blenderm tape where diplopia is worse
- Last resort complete occlusion
IV
Typical IV plan would be:
strong steroids first 6 weeks and then reduced
IF DON’T improve after first 6 weeks, most likely inactive phase
→ 500 mg methlyprednisolone weekly for 6 weeks
→ 250 mg for 6 weeks
→ This gives a cumulative dose of 4.5 g
OTHER medical treatments
- Other immunosuppressants may be indicated if the disease relapses following steroid withdrawl.
- Azathioprine
- Rituximab (Monoclonal Antibody) – depletes B lymphocytes
Complications of IV
- If there is no clinical response after the first 6 weeks steroids maybe discontinued
- Care should be taken not to exceed 8g in total. Fatalities have only been reported whe this dosage has been exceeded
Severe side effects have occurred in patients receiving daily or alternate singles doses higher than 500mg
Systemic treatment
- Only patients with active disease will respond to immunosupressive treatments such as corticosteroids or orbital radiation
- IV vs Oral Glucocorticoid Zang et al 2011
- IV steroids are thought to have fewer side effects, shorter treatment courses and lower relapse compared to Oral
Orbital radiotherapy
Radiation reduces inflammation in orbit
- Often used in conjunction with steroid therapy
- It is particularly effective in ocular motility involvement and compressive optic neuropathy
- Low side effects
- Radiotherapy acts directly on the highly radiosensitive lymphocytes that are infiltrating the orbital space
- By reducing the secretion of pro-inflammatory cytokines from activated lymphocytes
- Usually 12 rounds of radiation is enough
- Longer lasting effect than steroids alone
Surgical treatments
Decompression - if severe in early active phase
Strabismus Surgery - to get rid of double vision
Eyelid recession - to allow eye to come down
Blepharoplasty - suturing eyelid together to reduce proptosis
Blepharoplasty
Carried out at end of TED journey
- Upper and/or Lower eyelid blepharoplasty maybe required as a final procedure in the functional and cosmetic outcome in Graves patients
- Both skin and prolapsed orbital fat are removed
Greatly improves the appearance if still exophthalmos
DECOMPRESSION
- In the active phase surgical decompression of the orbit may be necessary if the steroids/radiotherapy are not reducing the inflammation sufficiently.
- CON – need to act quickly and decompress the orbit
- Inactive phase for MARKED proptosis
- Medial/Lateral wall/ Floor
- Improved proptosis, improved orbital venous and lymphatic drainage
- Complications of increased diplopia
- The more walls removed the greater the reduction in proptosis
