thyroid eye disease, tumors, lesions and surgeries of the orbit

hypothyroidism

decreased production of thyroid hormones

• can be structurally or functionally induced

most common cause of hypothyroidism

1. hashimotos thyroiditis autoimmune mediated attack of the thyroid gland

2. iodine deficiencies in developing countries

signs/symptoms of hypothyroidism

1. cold intolerance

2. fatigue

3. weight gain

4. dry skin

5. course hair

diagnostic testing for hypothyroidism

1. increased TSH

2. decreased T4, T3, antithyroid antibodies

bio of hypothyroidism

1. inc TSH from pituitary

2. thyroid gland doesnt make as mucuh T3, T4

hyperthoidism most common caus e

1. graves disease - autoimmune disease of TSH autoantibodies constantly stimulating thyroid gland

2. FEMALE predilection

signs of hyperthyroidism include

1. heart palpitations

2. weight loss

3. heat intolerance

4. hair loss

diagnostic testing foro hyperthyroidism

1. decreased TSH

2. increased T4, T3, anti-thyroid antibodies

hyperthyroidism biology

no TSH fro pituitary

increased T3, T4 from thyroid

thyroid eye disease cause

1. autoimmune process that mostly affects pt w graves disease

2. can occur w other autoimmune diseases of the thyroid

who gets TED

1. middle aged women

   1. when men get it tho its more severe

whats the controlable risk for TED

1. smokers

2. (severe presentation)

what is TED the most common cause of

unilateral or bilateral proptosis in adults

pathophys of TED

1. autoimmune process affecting fibroblasts of the orbit found on orbital fat and EOM

2. orbital fibroblasts trigger inflammation

   1. stimulation of T and B lymphocytes

   2. production of pro inflammatory ccytokines

   3. accumulation of GAGs

3. —> orbital fat expansion of EOM enlargement

4. —> proptosis/diplopia

what are the general 4 clinical signs of TED

1. eyelid disorders

2. ocular surface disorders

3. EOM disorders

4. ONH disorders

whats the progression of TED

1. NOSPECS

2. no ocular signs or symptoms

3. only signs, no symptoms

4. soft tissue swelling

5. proptosis

6. EOM involved

7. Corneal involvement

8. sight loss form ON head involvement

what does TED eyelid disorders include

1. eyelid retraction

2. eyelid edema

3. reduced blinking

4. lid lag (von grafe sign)

eyelid retraction sign TED

1. upper eyelid is too high and lower eyelid is too low

2. Dalyramples sign - retraction of the upper lid on primary gaze

eyelid edema/reduced blinking sign TED

Enroth’s sign - lid puffines

• eyelid edema: upper>lower lid

Stellwig’s sign - infrequent blinking

lid lag sign TED

1. Von grafe sign - lid lag on inferior gaze

ocular surface disorders TED

1. superficial keratopathy

2. conjuntival injection

3. superior limbic keratoconjunctivits

4. proptosis

superficial keratopathy in TEd

1. exposure keratopathy

   1. can lead to corneal ulceration, pannus, or perforation if not treaed

2. due to the increased surface area of eye exposed to air —> bc lids are retracted

3. also called SPK, PEE (loss of ep cells

conjunctival injection in TED cause

1. dryness of ocualr surface causes inflammation of the conj

superior limbic keratoconjunctivitis TED cause

1. thouguht to arise from constant friction btw the superior bulbar conj adn the tarsal conj

what are the norms for whites exophthalmometry range

12-22 mm

what are the norms for black exophthalmometry range

12-24 mm

what are the norms for asian exophthalmometry range

12-18 mm

what asymmetry in exophthalmometry is abnormal

3 mm

what are the EOM disorders of TED

1. eom restriction

2. resistance to retropulsion of the globe

whats the order that the EOMs get affected in TED

1. IM So Lazy

2. IR, MR, SR, LR

if theres movement in forced duction

1. negative force duction

if theres not movement in forced duction

1. positive force duction

2. EYE WILL NOT MOVE IN DIRECTION OF ACTION
   mechanical obstruction (TED)

what are ONH disorders w TED

1. decreased VA

2. decrease color vision

3. positive RAPD

4. visual field defects

MOST SEVERE W POTENTIAL FOR IRREVERSIBLE VISION LOSS

what are TED symptoms

1. asymptomatic to decreased vision (depensd on severity)

2. red eye

3. foreign body sensation

4. tearing

5. bulging eyes

6. retracted eyelids

7. diplopia

8. decreased vision

9. dyschormatopsia

clincial exam of TED

1. medial histroy

   1. histroy of throid, autoimmune, or cancer

   2. ask about symptoms of hyper/hypo thyroidism

   3. ask if they smoke

2. entrance testing

3. obtain VF tests - will be helpful if it progresses to involve ON

what labs/tests do we do for TED

1. TSH

2. T3,T4

3. thyroid autoantibodies

4. obrital CT scan w contrast

   1. EOM enlargement w sparing of the tendons

      1. IM So Lazy

when we see what in CT scans we think TED

Coke bottle EOM

what do we do to manage TED

1. can’t do irrecersible interventions until a 6 mo stable interval is recorded

   1. exception is Optic neuropathy or extreme proptosis causing severe exposure keratopathy or corneal ulceration

2. sx intervention after a 6 mo quiesent interval

   1. first: posterior sx

   2. second: anterior sx

3. underlying disease is managed by endocrinolofy

4. smoking cessation education

what do we do for TED eyelid retraction

1. sx eyelid recession after 6 mo interval of stable incerval

2. refer to oculoplastics

how do we manage TED ocular surface issues

1. corneal protection

   1. topical lubrication (PF-AT) q1hr-PRN

      1. gels/ointments at bedtime

   2. topical immunomodulator

      1. restasis 1 drop BID-6x OU a day

      2. Xiidra 1 drop BID OU

      3. Cequa 1 drop BID OU

   3. lid taping

   4. punctal occlusion

   5. sew part of eyelid closed

how do we treat proptosis/diplopia in TED

1. systemic steroids

2. Topezza - IV - q3 weeks x 8 cycles

3. fresnel prisms

4. strabismus sx - only after 6 mo stable interval and orbital sx is done

how do we treat compressive optic neuropathy in TED

1. systemic steroids

2. orbital decompression sx - refer to oculoplastics

whats Topezza side effect

ototoxicity

what are the 2 tumors and lesions of the orbit

1. orbital cavernous hemagioma

2. rhabdomyosarcoma

cause of orbital cavernous hemagioma

1. most common neoplasm in adults

2. presents around age 20-40

3. more in women

presentation of orbital cavernous hemagioma

1. slow progressive vascular neoplasm of endothelial lined spaces by a fibrous capsule

2. Main location - wi common tendinous ring

3. proptosis

signs of orbital cavernous hemagioma

1. motility defects

2. proptosis

3. ONH swelling

symptoms of orbital cavernous hemagioma

1. painless progressive proptosis

2. as the tumor grows it may involve EOM and ON

how are orbital cavernous hemagioma managed/treated

1. for small asymptomatic lesions - monitor every 6 mo w eye exam and imaging

   1. MRI TRICKS

2. sx excision for large - symptomatic lesions

rhabdomyosarcoma epi

1. most common childhood primary orbital malignancy

2. presents wi first decade of life

3. males more likely to develop

presentation of rhabdomyosarcoma

history of nosebleesd

rapidly progressie proptosis that may mimic an inflamatory procss

rhabdomyosarcoma signs

1. palpable mass and ptosis ocur 1/3 the time

2. swelling and injection over the skin develop - but the skin is not warm

what do lab studies and images shoaw of rhabdomyosarcoma

1. Ct scans - homogenous density usually adjacent to bony structure

2. systemic investigation - to rule out metastasis — lung and bone

whats the differential diagnosis for rhabdomyosarcoma

orbital cellulitis

treatment of rhabdomyosarcoma

1. radiation adn chemo

2. sx excision is for rare recurrent or radioactive resistant tumors

3. cure rate is 95% if in orbit only

what are the orbital sx

1. enucleation

2. evisceration

3. exenteration

enucleation

1. detach the EOM and remove the entire eyeball - intraocular contents adn scleral shell

2. keep EOM

3. spherical implant to maintain volume - eoms atach to it

4. after sx a conformer is placed into socket so there can be a prosthetic in the future

   1. if not there could be adhesion of palpebral and bulbar conj

why is enucleation done

1. intraocular malignancy

2. trauma

3. body attacking eye - sympathetic ophthalmia

4. microophthalmos

5. EYE IS BLIND AND PAINFUL

who makes an eye prosthetic

ocularist

evisceration

1. removes intraocular contents but keeps the scleral shella dn EOMs

2. spherical implant wi the scleral shell

3. conformer

4. prosthetic

why woudl you do evisceration

1. endoophtalmitis

2. penetrating ocular injury

3. blind painful eye

why is evisceration better than enucleation

1. shorter sx

2. less complex sx

3. more cost efficient

4. less disruption of orbital tissues

5. improved mobility

6. less change of spread of infection to nervous system

7. less painful

disadvantages of evisceration over enucleation

1. risk of sympathetic opthalmia

   1. attacks good eye

2. risk of dissemination of intraocular tunors

exenteration

1. removes eyeball and surrounding tissues (lids, nerves, fatty tissue, muscles)

reasons for exenteration

1. malignant tumor which involves eyelids or structures beding the eye

2. to prevent metastatic spread of tumor via blood stream

3. cosmetic sticker possible