thyroid associated orbitopathy of dr. sohel mahmud
TRANSCRIPT
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Thyroid associated orbitopathy
Presentation is made by
Dr. Sohel MahmudMBBS, DO.
Eye specialist & surgeonDhaka, Bangladesh.
A stone made statue of a
man with unilateral
proptosis at the time of
ancient Greece.
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Introduction Thyroid
associate
d
orbitopat
hy
Graves’
ophthalmop
athy
Thyroid
orbitopat
hy
Dysthyroid
ophthalmopa
thy
Thyroid
eye
disease
Thyrotoxic
exophthal
mos
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Introduction cont...
Thyroid-associated orbitopathy (TAO) is
an autoimmune inflammatory disorder that
can affect the orbital and periorbital tissue,
the thyroid gland and rarely the pretibial
skin or digits.
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Epidemiology TAO • Commonly presents during fourth and fifth decades• Median age at the time of diagnosis 43years• Range 8-88years
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Epidemiology of TAO cont...
86%Women
14% Men TAO affects women approximately 6 times
more frequently than men.
Smokers are up to 7 times more likely
than nonsmokers to develop TED. 89%Smokers
11%Nonsmokers
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Etiology
• TAO typically associated with Graves’ hyperthyroidism but may also occur with Hashimoto’s thyroiditis or in absence of thyroid dysfunction
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Pathogenesis
CD1
54
Orbital
fibrobla
st
T
cell
Up-regulation –
1. IL-6
2. IL-8
3. PGE2
Synthesis of-
Hyaluronan
GAG is
increased
Derived from
neural crest and
possess
developmental
plasticity
1
A subpopulation
undergoing adipocyte
differentiation causing fatty
hypertrophy particularly in
those younger than 40
years
2
Up-regulation of
TSH-R mRNA
synthesis
Adipogenesis-
Expansion of
orbital fat
compartment
3
Circulating IgG
activates insulin like
growth factorFound
in a
majority
with
Graves
disease
4
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HistopathologyFindings on histological examination-
• Fibrosis with degenerative changes in the eye
muscles
• Lymphocytic cell infiltration
• Enlargement of fibroblasts
• Accumulation of mucopolysaccharides
• Interstitial edema
• Increased collagen production
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Grossly
Enlarge extraocular muscles in TAO
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Clinical features of TAO
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Eye signs of TAO
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Dalrymple
sign
Von Graefe
sign
Kocher
sign
Goldzieher’s
sign
Courtesy by oculoplasty dept. of
NIO&H
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Mechanism of lid retraction
•Fibrotic contracture of the levator
•Secondary overaction of the levator superior
rectus complex
•Humorally induced overaction of muller muscles
Courtesy by oculoplasty dept. of
NIO&H
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Proptosis• Axial• Uni/bilateral• Symmetrical/ asymmetrical
Severe proptosis leads
to -
•Exposure keratopathy
•Corneal ulcer
•Infection
Courtesy by oculoplasty dept. of
NIO&H
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Restrictive myopathy
• Initially by inflammatory edema later for fibrosis
•Elevation defect
•Abduction defect
•Depression defect
•Adduction defect
Courtesy by oculoplasty dept. of
NIO&H
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Optic neuropathy
• Uncommon but serious complication• Caused by compression of the optic nerve or its
blood supply at the orbital apex
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Stages TAO
•Congestive
•Static
•Fibrotic/quiescent
Courtesy by oculoplasty dept. of
NIO&H
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NOSPECS classification of TAO
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Systemic features
Hypothyroid Hyperthyroid
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Goitre
Pretibial
myxoedema
Acropachy
Vitiligo
Systemic features cont…
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InvestigationThyroid function test-
OthersUSG of thyroid glandThyroid scanningFNACThyroid scintigraphyECGEchocardiography
•Serum free T3,T4,TSH
•Thyroid stimulating immunoglobulin
(TSI)
•Thyroid binding inhibitory Ig
•CT scan of orbit and brain
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Investigation cont…
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Courtesy by oculoplasty dept. of
NIO&H
•Fusiform enlargement of muscle
•Tendon spearing
•Muscle border smooth
On CT scan of orbit and brain-
Investigation cont…
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Diagnostic criteria
The diagnosis of TAO is made when 2 of the following 3 signs ofthe disease are present:
1. Concurrent or recently treated immune-related thyroid
dysfunction (l or more of the following):
a. Graves hyperthyroidism
b. Hashimoto thyroiditis
c. Presence of circulating thyroid antibodies without a
coexisting dysthyroid state (partial consideration given):
TSH-receptor (TSH-R) antibodies, thyroid-binding
inhibitory immunoglobulins (TBll), thyroid-stimulating
immuno-globulins (TSI), antimicrosomal antibody.
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The diagnosis of TAO is made when 2 of the following 3 signs ofthe disease are present:
2. Typical orbital signs (l or more of the following):
a. Unilateral or bilateral eyelid retraction with typical
temporal flare (with or without lagophthalmos)
b. Unilateral or bilateral proptosis (as evidenced by
comparison with
patient's old photos)
c. Restrictive strabismus in a typical pattern
d. Compressive optic neuropathy
e. Fluctuating eyelid edema/erythema
f. Chemosis/caruncular edema
Diagnostic criteria cont…
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The diagnosis of TAO is made when 2 of the following 3 signs ofthe disease are present :
If only orbital signs are present the patient should continue tobe observed for other orbital diseases and for the futuredevelopment of a dysthyroid state
3. Radiographic evidence of TAO- unilateral/bilateral
fusiform enlargement
of 1 or more of the following :
a. Inferior rectus muscle
b. Medial rectus muscle
c. Superior rectus/levator complex
d. Lateral rectus muscle
Diagnostic criteria cont…
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Treatment of TAO
Supportive measures
Medical management
Orbital radiation therapy
Surgical management
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Treatment of TAO cont…
1. Smoking
cessation
2. Lubricating eye
drops
3. Cool compression
4. Salt restriction
5. Elevation of head
6. Wearing sunglass
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Treatment of TAO cont…
1. Systemic corticosteroids
•Starting dose 60-100 mg orally
•Short-term pulse intravenous dose 1gm daily
several
times a weak for up to 2 months
2. Others
• Cyclosporine
• Ticlopidine
• Intravenous immune globulin
• Somatostatin analogues
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Treatment of TAO cont…
• Orbital irradiation is prescribed for moderate to severe
inflammatory
symptoms, diplopia and visual loss in patients with TAO
• Typical dose 2000 rad to each orbit, delivered as 200
rad/day for
10 days
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Treatment of TAO cont…
1. Orbital
decompression
2. Strabismus surgery
3. Eyelid surgery
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Treatment of TAO cont…
• Observation
• Patient education/lifestyle
changes
• Smoking cessation
• Salt restriction
• Elevation of head of bed
• Wearing sunglasses
• Ocular surface lubrication
• Topical cyclosporine
• Eyelid taping at night
• Moisture goggles/chambers
• Prism glasses or selective ocular
patching
• Moderate-dose oral steroid therapy
• High-dose oral steroid therapy
• Intravenous steroid therapy
• Surgical orbital decompression
• Strabismus surgery
• Eyelid surgery
• Periocular radiotherapy
Refractory disease
• Steroid-sparing immunomodulators
(rituximab)
Mild
diseas
e
Moder
ate
diseaseSevere
disease
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Prognosis• TAO is a self-limiting disease • On average lasts 1 year in nonsmokers and between 2 and 3
years in smokers• After the active disease plateaus, a quiescent burnt-out phase
ensues • Reactivation of inflammation occurs in approximately 5%-
10% of patients over their lifetime
Poor prognostic features-
• Smoking
• Rapidly progressive (typically
congestive) TAO
• Presence of myxoedema
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THANK YOU & THANK TO
THEM