Thyroid Eye Disease

Question 1

Define thyroid eye disease

Answer 1

A complication of autoimmune hyperthyroidism (Grave’s disease) that results ins welling of the extraocular muscles and orbital fat

Question 2

Aetiology of thyroid eye disease

Answer 2

1. Inflammatory phase
   - Idiopathic and autoimmune inflammatory process (6-24 months)
   - Evidence suggests that an autoimmune reaction to TSH receptors results in lymphocyte infiltration into orbital tissues, which initiates an inflammatory process
   - Responsive to medical management
2. Inactive fibrotic phase
   - Non-responsive to medical therapy

Question 3

Risk factors for thyroid eye disease

Answer 3

Smoking – the most important risk factor for development and increased severity of TED in patients with Grave’s disease
Family history of Grave’s disease and other autoimmune disease
Female sex
Poor thyroid control

Question 4

Epidemiology of thyroid eye disease

Answer 4

Roughly half of patients with Grave’s disease develop TED
80% of cases of TED are due to Grave’s disease

Question 5

Symptoms and signs of thyroid eye disease

Answer 5

Ocular pain – often worse on movement
Dry, red eyes → inability to close eyelids
‘Bulging eyes’
Painful eyelids

Proptosis/exophthalmos
Lid retraction and lid lag
Chemosis
Orbital fat prolapse
Exposure keratopathy

Question 6

Management for thyroid eye disease

Answer 6

1. Conservative:
   - Artificial tears
   - Ointments
   - Prisms (for diploplia)
2. Optimise thyroid control
3. Steroids
4. Immunosuppression

Sight-threatening → urgent surgical orbital decompression → IV corticosteroids

Question 7

When is urgent review required for thyroid eye disease

Answer 7

(EUGOGO guidelines)
unexplained deterioration in vision
awareness of change in intensity or quality of colour vision in one or both eyes
history of eye suddenly ‘popping out’ (globe subluxation)
obvious corneal opacity
cornea still visible when the eyelids are closed
disc swelling

Question 8

Complications of thyroid eye disease

Answer 8

Exposure keratopathy – where corneal damage and infection occur as the patient is unable to close their eyes
Compressive optic neuropathy – occurs when the retro-orbital swelling begins to compress on the optic nerve
suspect this when signs of optic nerve involvement occur – reduced visual fields, reduced colour vision, reduced visual acuity, relative afferent pupillary defect
Diplopia – due to fibrosis of the extraocular muscles limiting gaze in various directions