Grave’s Disease (Thyroid Related Ophthalmopathy)

Grave’s Disease (Thyroid Related Ophthalmopathy)
SYMPTOMS Foreign body sensation, diplopia, reduced vision
SIGNS Upper eyelid retraction (w/lateral flare), upper lid lag on downgaze (pseudo-von Graefe sign), proptosis, lagophthalmos, periorbital/lid swelling, EOM restriction, exposure keratopathy, optic nerve swelling due to compression
Progression/Severity of Grave’s Disease (NOSPECS) N: No symptoms or signs O: Signs but no symptoms S: Soft tissue involvement P: Proptosis E: EOM involvement C: Corneal involvement S: Optic nerve involvement
WORK-UP Thorough history: Ask about surgery, thyroid levels, diplopia. Thorough ocular examination: Check for EOM restrictions, proptosis, keratopathy, IOP, and optic nerve edema Exophthalmometry Forced duction testing: Restriction noted with Grave’s disease Corneal staining OCT (If suspecting optic nerve involvement)
TREATMENT Refer for proper thyroid management. Cessation of smoking. Topical lubrication drops during the day/ Topical lubrication gel at night
Tepezza (First FDA approved treatment for thyroid eye disease) Oral prescription medication that can be prescribed by PCP and ophthalmology
Refer to oculoplastic specialist if surgery such as EOM, eyelid, or orbital surgery is needed
FOLLOW-UP Close follow-up in severe cases. Approximately every 6 months for mild cases.
ADDITIONAL LAB | TESTS CT of orbit, Thyroid panel (TSH, T3, T4, anti-thyroid antibodies), CBC with differential
ETIOLOGY Usually associated with hyperthyroidism, but TED may occur in patients with euthyroid or hypothyroidism.
DIFFERENTIAL DX Orbital tumor, Orbital myositis, C.N. III palsy with aberrant regeneration, Significant contralateral ptosis (due to Hering’s law)
NOTES Keep in mind that there may systemic issues as well such as weight loss, fine hair, pretibial myxedema, hand tremor,insomnia, and increase in sweating.
Corticosteroid use and radiation therapy remain controversial. Myasthenia gravis may present with TED.
Thyroid eye disease
Thyroid eye disease CT SCAN