Thyroid Eye Disease Flashcards
What is the hallmark of orbital disease?
Proptosis/Exophthalmos
T/F: MRI/CT scan is necessary for diagnosis of TED
FALSE
Proptosis + Adenopathy may be associated with…
Systemic lymphoma or METS
5 Physical (non-ocular) tests for proptotic patients
- Blood tests
- Thyroid palpation
- Lymph node palpation
- Sinus testing
- Body temperature
What is a normal exophthalmometer measurement?
Normal is 17 mm
Most people are less than 22
Intraocular exophthalmometer difference of ___ mm is considered abnormal
2 mm
How often should exophthalmometry be measured in TED patients?
1-3 months
Exophthalmometer measurement increase of ___ mm indicates progression of TED.
2 mm
T/F: Collier’s Sign is found in Thyroid Eye Disease
FALSE
(+) Collier’s in children can indicate…
- Congenital aqueduct stenosis
- Hydrocephalus
What is the most common cause of Orbital Disease
TED
TED is also referred to as
- Graves Ophthalmopathy
- Thyroid-Associated Orbitopathy
TED is more common in ____ (males/females) and more severe in ___ (males/females)
Common — Females
Severe — Males
Is TED an immune or an inflammatory disorder?
BOTH
Why is TED related to edema?
Increase in “materials” attracts fluid
What are 3 possible mechanisms for TED?
- Inflammation of perioribital soft tissue
- Overproduction of glycosaminoglycans
- Hyperplasia of adipose tissue
T/F: Most patients with TED also have MG
FALSE — only 1-2%
Still recommended to perform chair-side MG tests on all TED patients
TED usually most presents at age…
20-60
T/F: controlled Thyroid Disease rarely manifests ocular symptoms
FALSE
T/F: TED can occur in pts with hypothyroidism
TRUE
Hyper, hypo, or euthyroid
What percent of Euthyroid patients with TED will eventually develop systemic thyroid disease?
70%
Most common tumor DDx for TED in adults
Lymphoma
T/F: IOIS is more common in adults, but can occur in pediatric patients
TRUE
Most common DDx for TED in adults
- Tumor (esp Lymphoma)
- Infectious (Preseptal or Orbital)
- Dural Sinus Fistula
- Metastasis
- IOIS
DDx for TED in children (3)
- Congenital
- Infectious (Preseptal or Orbital)
- Malignancies (rhadbomyosarcoma**, neuroblastoma, Ewing’s, and retinoblastoma)
NOSPECS classification
No physical symptoms
Only signs (no symptoms)
Soft tissue involvement
Proptosis
EOM involvement
Corneal involvement
Sight loss
Describe the early stage of TED
Non-specific inflammatory signs/symptoms
Describe the inactive stage of TED
- Lid abnormalities (retraction, edema, lagophthalmos)
- Diplopia/vision loss
Vision loss associated with TED is usually due to (2)
Optic neuropathy or corneal involvement
Is suspecting TED, but pt c/o pain, the diagnosis is more likely…
- IOIS
- Infections
- Tumor
TED onset is typically ___ (gradual/sudden)
Gradual
What are the limitations of the NOSPECS classification system?
Does not distinguish inflammatory progression from non-inflammatory progression
___ is one of the most popular classification methods for TED today
Clinical Activity Score (CAS)
Why was the CAS system formed?
To discriminate easily between active and quiescent stages of TED
What CAS score is indicative of active TED?
Above 3/7 on initial visit or 4/10 on successive visits
What are the main systems graded by the VISA?
Vision
Inflammatory
Strabismus
Appearance/Exposure
What inflammatory score on the VISA scale warrants ‘aggressive’ therapy?
5/10
What is the main benefit of EUGOGO?
Picture atlas for comparison
Studies show that ____% of orbitipathy pts improve, ___% remain stable, and ___% worsen
50% improve
35% remain stable
15% worsen
General “First Step” Treatments for TED
Diamox (CAI)
Artificial Tears
Tape Lids at night
Elevate Head
Prism
Avoid pre-op iodine
Gazing in all directions
Educate patient
Steroid injections
Treatment for mild TED?
“General first steps” + oral selenium (100 µg 2x/day)
Benefits of selenium
Improves quality of life, reduces ocular involvement, and slows progression of TED
Which delivery method proved to have a highest response rate?
IV (82%) vs oral (53.4%)
What are benefits of IV steroids?
- Higher response
- Fewer side effects
- Shorter tx time
- Lower relapse rate
Cumulative dose of steroids should not exceed…
8g
Commonly used steroid regimen for moderate TED
500 mg methylprednisolone x 6 wk
Then, 250 mg x 6 weeks
CI for steroid treatment of TED
- Liver dysfunction/recent hepatitis
- Severe CVD or HTN
- Psych disorders
- Uncontrolled DM
for all pts, liver enzymes, glucose, and BP should be monitored monthly
Management for moderate TED
Steroids + Orbital radiotherapy
Management of Sight-Threatening TED
High dose IV steoroids (500-1000 mg for 3 days)
If poor response within 2 weeks or if (+) choroidal folds or eyeball subluxation, orbital decompression!!
Selenium can be found in… (food)
Meat, fish, eggs, cereals…
What is the general mechanism for selenium that improves TED
Involved in cellular redox state —> has antioxidant and immunomodulatory effects
Most feared complication of TED?
Optic neuropathy
T/F: vision loss can be reversed with TED
TRUE; medial and lateral decompression highly successful in reversing VL
Common VF defects with ON neuropathy (4)
- Enlarged blind spots
- Nerve fiber defects
- Central or cecocentral defects
- General constriction
T/F: only a small percentage of TED pts experience vision loss
TRUE (2-9%)
TED f/u’s should include:
- VF
- Color vision (monocular)
- Contrast sensitivity
- VEP
- R/o pallor, swelling, and hyperemia
- Assess for MG
Long-standing muscular edema along with increased production of collagen leads to…
- Atrophy
- Fibrosis
- Sclerosis (of EOM)
- Restrictive strab
F/U’s for TED should occur every ____
1-3 months
