Thyroid eye disease/systemic disease and eye

Question 1

Prevention of thyroid eye disease?

Answer 1

Smoking Is the most important modifiable risk factor.
Radioiodine treatments may worsen thyroid eye disease.

Question 2

Features of thyroid eye disease?

Answer 2

Exopthalmos
Conjunctival oedema
Optic disc swelling
Ophthalmoplegia
Inability to close eyes

Question 3

Management of thyroid eye disease

Answer 3

Smoking cessation,
Topical lubricants/ artificial tears,
Selenium supplements.
Steroids - if sight threatening features,
Radiotherapy,
Surgery

Question 4

Complications of thyroid eye disease

Answer 4

Exposure keratopathy (most common complication) - eye exposed leading to dryness, irritation and corneal ulceration.
Optic neruopathy - serious complication resulting in reduced visual acuity, poor colour vision and visual field defect
Strabismus and diplopia

Question 5

What symptoms indicate a patient with thyroid eye disease needs an urgent review by ophthalmologist?

Answer 5

Unexplained deterioration in vision,
Change in colour vision,
Global subluxation,
Corneal opacification,
Cornea visible when eye is closed,
Disc swelling

Question 6

What signs may you seen in HTN retinopathy on ophthalmoscope?

Answer 6

Retinal arterial narrowing, Focal narrowing, retinal haemorrhages, macular stars, cotton wool spots, swollen discs, AV nipping, copper wiring.

Question 7

What screening is done for JIA?

Answer 7

Regular assessments of Uveitis

Question 8

HLA B27 associations

Answer 8

PEAR
Psoriatic arhtirits
Enterocolitis - IBD
Ank spond
Reactive arthritis

Question 9

Features of Uveitis

Answer 9

Inflammation of iris.
Mildly painful, typically doesn’t wake pt up, photophobia.
May have irregular pupil and cells in anterior chamber +/- hypopyon.

Question 10

Features of scleritis

Answer 10

Very painful and red eye - wakes patient up from sleep.
Deep boring pain, tender globe and red eye which doesn’t blanch with phenylephrine.
Treat with oral steroids

Question 11

Blood markers are raised in GCA?

Answer 11

ESR
CRP
Platelets

Question 12

Sight threatening complications in thyroid eye disease

Answer 12

3 main:
1. Optic nerve issues
2. Glaucoma
3. Corneal breakdown.

Question 13

Features of CN 3 palsy?

Answer 13

1. ptosis/complete ptosis
2. Pupillary dilation
3. Eye down and out.

Question 14

Investigation of CN3 palsy?

Answer 14

Anyone with new CN 3 palsy should have CT angiogram - Rule out posterior communicating artery aneurysm.
Especially important if headache.

Bloods - because most common cause is microvascular damage. GCA can also cause.

Management - Control diplopia, surgery if aneurysm

Question 15

Features of CN 6 palsy

Answer 15

Signs - loss of abduction. Can be caused by raised ICP

Management:
- Urgent neruo-imaging if other neuro red flags present.
- Bloods (commonly caused by microvascular damage)
- Then control diplopia and reassess in 6 weeks.

Question 16

Features of CN 4 palsy

Answer 16

Presentation - Hypertropia, positive Park- Bielschowsky/head-tilt test.

Management:
- Bloods
- Then manage

Question 17

Bilateral papilloedema presentation and investigations

Answer 17

Presentation - blurred disc margins, flame haemorrhage, cotton wool spots, obscured blood vessels, absence of venous pulsation

Do CT head - SOL
LP - opening pressure
Venography

Question 18

Causes of Horner’s

Answer 18

Anhidrosis of face - Pancoast tumour, thyroidectomy, trauma
No anhidrosis - Carotid dissection - new horner + neck pain/trauma/headache then must do CT angiogram. Carotid aneurysm, CST and cluster headache.
Anhidrosis of face/arm/trunk - stroke, syringomyelia, MS

Question 19

Investigations of Horner’s syndrome

Answer 19

Topical apraclonidine - horners pupil dilates.
If neck trauma/pain/headache - URGENT CTA
If not acute then do MRI head + neck + thorax +/- angiogram

Question 20

Presentation, investigations and management of myasthenia gravis

Answer 20

Presentation - variable diplopia, ptosis and limb weakness. Ptosis, diplopia, fatiguability.

Ix - Anti achytilecholine receptor antibodies, anti-MUSK antibodies. CT thorax - thymoma.

Rx - Anticholinesterase (pyridostigmine) and steroids/immunosuppresion.