Thyroid Eye Disease

Question 1

What are the risk factors for TED?

Answer 1

female, middle-aged, smoking, autoimmune thyroid disease

Question 2

What are the ocular symptoms of TED?

Answer 2

• Soft tissue involvement – eye irritation, photophobia, tearing (lacrimation), retrobulbar discomfort
• Diplopia (2’ to ophthalmoplegia)
• Blurring of vision (BOV)
• Pulling sensation when moving eye +/- pain

Question 3

What are the ocular signs of TED?

Answer 3

• Lid retraction: superior scleral show due to retraction
• Lid lag
• Exophthalmos: forward displacement of eye by increased retro-orbital fat
• Proptosis
• Restricted extraocular muscle movements: IR -> MR -> SR -> LR; “I M So Lazy”
• Chemosis
• Exposure keratopathy/ corneal ulceration
• optic neuropathy (due to oversized recti and orbital fat causing compartment syndrome at the apex of the orbit)

Question 4

what is the sight threatening complications of TED?

Answer 4

• exposure keratopathy
• Compressive optic neuropathy (an emergency in context of TED!): decreased VA, colour vision loss, red desaturation, visual field loss, unilateral or bilateral optic disc swelling
• glaucoma: (IOP increases especially in upgaze due to tightness of IR which abuts the orbital wall when attempting to look upwards), esp when sleeping due to Bell’s reflex

Question 5

What is the management of TED?

Answer 5

• systemic: carbimazole, propylthiouracil, radioactive iodine, thyroidectomy
• ocular: smoking cessation, PO/ IV short course steroids
• exposure keratopathy: lubricants, taping, sunglasses
• glaucoma: IOP lowering eye drops
• compressive optic neuropathy: urgent po/ iv steroids, orbital decompression (if no improvement after 2-3 days)