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Grave’s Ophthalmopathy (GO)
Clinical presentation
&
Medical treatment
Parima Hirunwiwatkul, MD
Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University
Clinical presentation
• Dryness and irritation
• Inflammation and pain
• Visual disturbance
– Afferent: Decrease acuity, dimming, scotoma,
color change
–
• Cosmetic
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Eye involvement in GO
Class 0 • No symptoms or signs
Class I • Only signs, no symptoms (lid retraction, stare, lid lag)
Class II • Soft tissue involvement
Class III • Proptosis
• Extraocular muscle involvement
Class V
• Corneal involvement
Class VI • Sight loss (optic nerve involvement)
Treatment of TRO
• Avoid risk factors
• ymp oma c rea men
– Lubricant
– Anti‐inflammation : steroids
• Medical treatment
– Systemic steroids
– Immunosuppressive
– Botulinum toxin
• Surgical treatment
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Lubricants
• Artificial tears:
– Preservative artificial tear
– Disappeared preservative
– Non preservative/ preservative free
• Form:
– – ,
– Eye gel
No symptoms or signs
• NoneSymptoms:
• NoneSigns:
• NoneTreatment:
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Only signs, no symptoms
• unequal eye Symptoms:
• Lid retraction, stare, lid lagSigns:
• Control thyroid hormone condition
• Botulinum toxin injected to Muller muscle
Treatment:
Soft tissue involvement
• Pain, irritation, redness,
• Deep conjunctival injection, especially over the rectus muscle insertions.
• Conjunctival chemosis
• Edema of the caruncle
• Inflammation may result in periorbital
cosmetic
Signs:
edema and erythema.
• Avoid risk, sleep position
• Lubricants
• Topical steroids (+ oral)Treatment:
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Proptosis
• Extruded eyeball from globe
• Dryness
• Proptosis
• Lagophthalmos
• Corneal exposure
Signs:
• Avoid risk, sleep position
• Lubricants• Tarsorrhaphy : medical/surgical
Treatment:
Extraocular muscle involvement
• Double vision
• Cannot move the eyes
• Misalignment of globe
• Limitation of eye movement by EOM involvement
Signs:
• Symptomatic: Patching, prism, Botulinum
toxin injected to Rectus muscle
• Systemic steroids
Treatment:
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Corneal involvement
• Dryness, pain, redness S m toms:
• ecrease v s on
• Conjuntival injection
• Corneal ulceration/ perforationSigns:
• u r can s, op ca an o cs
• Tarsorrhaphy : medical/surgical
• Corneal surface reconstruction: AMT, corneal transplantation
Treatment:
Sight loss
• Decreased visionS m toms:
• ↓ optic nerve function: color, brightness, contrast, VF
• RAPD ‐positive
• + Disc swelling/atrophy
Signs:
• Medical/surgical decompression: systemic/local steroids injection, Botulinum toxin injection, OR, surgery
Treatment:
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*This paper is also being published in the March 2008 issue of the journal,
European Journal of Endocrinology, vol. 158, no. 3.
Recommendations
Referral to combined thyroid‐
eye clinics and Smoking and GO
Management of hyperthyroidism in patients with
initial assessment GO
Other simple measures that may alleviate
symptoms
Grading severity and activity of GO
Management of sight‐threatening
GO
Management of moderate to
severe GO
Management of mild GO
Special situations
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should be addressed by
both nonspecialists and specialists
Referral to combined thyroid ‐eye clinics
and initial assessment
Should all patients with GO be referred to
Primary care physicians, general practitioners, general internists and specialists, who have no
com ne yro –eye c n cs
particular expertise in managing GO, should refer patients with GO, except for the mildest cases, to combined thyroid‐eye clinics for
further assessment and management
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Refer urgently
• Symptoms
–
– Awareness of change in intensity or quality of colourvision in one or both eyes
– History of eye(s) suddenly ‘popping out’ (Globe subluxation)
• Signs
– Obvious corneal opacity
– Cornea still visible when the eyelids are closed
– Disc swelling
Refer urgently
• Compressive optic neuropathy (Dysthyroid
op c neuropa y
• Exposure keratopathy … corneal melting
…corneal perforation
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Refer non‐urgently
• Symptoms – Eyes abnormally sensitive to light: troublesome or deteriorating over
the past 1–2 months
– lubricants
– Pain in or behind the eyes: troublesome or deteriorating over the past 1–2 months
– Progressive change in appearance of the eyes and/or eyelids over the past 1–2 months
– Appearance of the eyes has changed causing concern to the patient
– Seeing two separate images when there should only be one
gns – Troublesome eyelid retraction
– Abnormal swelling or redness of eyelid(s) or conjunctiva
– Restriction of eye movements or manifest strabismus
– Tilting of the head to avoid double vision
Smoking and
GO
Is smoking related to the occurrence,
All patients with Graves’ disease should be informed of the risks of smoking for GO emphasizing the detrimental effects of smoking on:
‐development of GO (IIb, B)
sever y, an progress on o
‐deterioration of pre‐existing GO (IIb, B)
‐effectiveness of treatments for GO (IIb, B)
‐progression of GO after radioiodine treatment (Ib, A)
If advice alone is ineffective, referral to smoking cessation clinics, or other smoking cessation strategies should be considered (IV, C)
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Management of hyperthyroidism in
patients with GO
1. Is correction of thyroid dysfunction
• Euthyroidism should be restored promptly and maintained
important for GO?
s a y n a pa en s w ,
• Frequent monitoring of thyroid status (every 4‐6 weeks) is imperative in the initial phases of treatment when changes in
thyroid status are expected (IV, C)
Management of hyperthyroidism in
patients with GO
2. Is there a relationship between modality of
• Patients with active GO given radioiodine should be offered prophylactic steroid cover (commencing with 0.3‐0.5 mg of prednisone/kg /day orally 1‐3
days after radioiodine and tapering the dose until withdrawal about 3
treatment or ypert yroi ism an t e course o GO
mont s ater I , A• Shorter periods of glucocorticoid therapy (1‐2 months) may be equally
protective (IV, C)
• Patients with inactive GO can safely receive radioiodine without steroid cover, as long as hypothyroidism is avoided (IIb, B), particularly if other risk
factors for GO progression, such as smoking, are absent (IV, C)
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Other simple measures
that may alleviate symptoms
Are there worthwhile simple measures that can
• Lubricant eye drops during the day and/or lubricant ointments at night‐time are recommended for all patients with GO who have
symptoms of corneal exposure (III, B)
• Patients with symptomatic diplopia should be given prisms if appropriate (IV, C).
• Botulinum toxin injection may be considered for upper lid retraction in centres who have experience and expertise in this
technique (IV, C).
should be addressed
in specialists centers
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Grading severity and activity of GO
Activity measures
based
on
features
of
inflammation:
clinical activity score (CAS)
Spontaneous retrobulbar pain
Pain on attempted up‐ or down gaze
Redness of the eyelids
Redness of the conjunctiva
Swelling of the eyelids
Inflammation of the caruncle and/or plicaConjunctival oedema
A CAS (sum of all items present) > 3/7 indicates active GO
Severity measures• Lid aperture
– distance between the lid margins in mm with the patient looking in the primary position, sitting relaxed and with distant fixation
• Swelling of the eyelids
•
• Redness of the conjunctiva
• Conjunctival oedema
• Inflammation of the caruncle or plica
• Exophthalmos – using the same Hertel exophthalmometer
• Subjective diplopia score – , ,
• Eye muscle involvement – ductions in degrees
• Corneal involvement (absent/punctate keratopathy/ulcer)
• Optic nerve involvement – best corrected visual acuity, color vision, optic disc, RAPD (absent/present), plus visual fields if
optic nerve compression is suspected
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Grading severity and activity of GO
Severity classifications
in
GO
1. Sight‐threatening GO:
atients with d sth roid o tic neuro ath DON and/or corneal breakdown.
This category warrants immediate intervention.
Grading
severity
and
activity
of
GO
Severity classifications in GO
2. Moderate to severe GO:
No sight‐threatening GO
Usually have any one or more of the following:
lid retraction > 2mm, moderate or severe soft tissue ,
gender, inconstant or constant diplopia.
Eye disease has sufficient impact on daily life to justify the risks of immunosuppression (if active) or surgical intervention (if inactive).
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Grading severity and activity of GO
Severity classifications
in
GO
3. Mild GO:
Only a minor impact on daily life insufficient to justify immunosuppressive or surgical treatment.
T ey usua y on y ave one or more o t e following: minor lid retraction (
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Management of mild GO
Is a ‘‘wait and see’’ strate reasonable?
Watchful waiting is appropriate for the
majority of patients with mild GO (IV, C).
Management of
mild
GO
How should mild eyelid retraction, soft tissue swelling,
the orbital disease?
In a minority of patients with mild disease, quality of life may be so profoundly affected as to justify using
treatments as for moderate to severe disease (IV, C).
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Early detection and referral to
ophthalmologist