Thyroid Eye Disease

Question 1

True or false: thyroid eye disease affects more men than women

Answer 1

False; it affects more women than men.

Question 2

Thyroid eye disease generally develops in what age range?

Answer 2

20-45 years

Question 3

What is the major clinical risk factor for developing thyroid eye disease?

Answer 3

Smoking

Question 4

True or false: thyroid ophthalmopathy can occur without any evidence of thyroid dysfunction

Answer 4

True; this actually occurs in 10-25% of cases.

Question 5

What are the four ways to classify thyroid eye disease?

Answer 5

By structure, NOSPECS, clinical activity score (CAS), and VISA

Question 6

Name the sign: puffy lids.

Answer 6

Enroth’s sign

Question 7

Name the sign: lid retraction.

Answer 7

Dalymple’s sign

Question 8

Name the sign: delay of the upper lid in following globe movement in downward gaze.

Answer 8

Von Graefe’s sign

Question 9

Name the sign: jerky downward movement of the lid

Answer 9

Boston’s sign

Question 10

Name the sign: delay of the lower lid in following globe movement in upward gaze.

Answer 10

Griffith’s sign

Question 11

Name the sign: globe lagging behind upper lid on upward gaze.

Answer 11

Kocher’s sign

Question 12

Name the sign: tremor of closed eyelids.

Answer 12

Rosenbach’s sign

Question 13

Name the sign: reduced blinking.

Answer 13

Stellwag’s sign

Question 14

Name the sign: increased pigmentation of eyelid skin

Answer 14

Jellinek’s sign

Question 15

In managing thyroid eye disease, what are some therapies you can use to help with the lid signs?

Answer 15

Lubrication (for cornea), topical alpha blockers (to relax muscles), beta blockers (relief of signs of thyrotoxicosis), botulinum toxin

Question 16

True or false: with proptosis, you can hear a bruit through the patient’s closed eyelid

Answer 16

True.

Question 17

EOM activity can be reduced with thyroid eye disease. Which EOMs are most affected, and what is the result? Are there any other signs from the EOMs?

Answer 17

IR is most commonly affected (diplopia on upgaze) and MR. IOP can raise on upgaze due to traction on the globe.

Question 18

What is the most common cause of unilateral proptosis?

Answer 18

Hyperthyroidism

Question 19

True or false: most patients with bilateral exophthalmos have Graves’ disease

Answer 19

True.

Question 20

In thyroid eye disease, the swelling of the EOMs can put pressure on the optic nerve, potentially causing loss of vision. Do many patients recover their sight?

Answer 20

70% of patients improve without treatment!

Question 21

What is NOSPECS and what does it stand for?

Answer 21

It’s a way to classify the severity of involvement. Generally, each class has the involvements of the previous classes:

No physical signs or symptoms (Class 0)
Only signs, no symptoms (i.e. upper lid retraction, stare, eyelid lag) (Class 1)
Soft tissue involvement (symptoms and signs) (Class 2)
Proptosis (Class 3)
EOM involvement (Class 4)
Corneal involvement (Class 5)
Sight loss (Class 6)

Question 22

What might you see in a Class 1 patient, according to NOSPECS?

Answer 22

Signs such as Darylmple’s or Von Graefe’s

Question 23

What might you see in a Class 2 patient, according to NOSPECS?

Answer 23

Lacrimal, photophobia, FB sensation, retrobulbar discomfort, lid/conjunctival edema/hyperemia, conjunctival chemosis, extrusion of orbital fat, lacrimal gland sweeling, inflammation near EOM insertion

Question 24

What might you see in a Class 3 patient, according to NOSPECS?

Answer 24

Proptosis

Question 25

What might you see in a Class 4 patient, according to NOSPECS?

Answer 25

EOM palsy (IR most commonly, then MR), leading to diplopia and IOP increase on attempted upgaze.

Question 26

What might you see in a Class 5 patient, according to NOSPECS?

Answer 26

Exposure keratopathy

Question 27

What might you see in a Class 6 patient, according to NOSPECS?

Answer 27

Sight loss, optic disc edema

Question 28

Some criticism about NOSPECS (inability to evaluate isolated components separately) lead to the creation of the clinical activity score (CAS). How does the CAS work?

Answer 28

In a nutshell, you have a list of signs and you tally one point per sign the patient has. The total number of points gives the patient a score toward severity of thyroid eye disease (?)

Question 29

What does VISA stand for? What does this classification system focus on?

Answer 29

Vision loss
Inflammation/congestion and activity
Strabismus/motility
Appearance/exposure.

The idea is to reflect the order in which problems should be managed.