TED

1. Case Presentation
Presenter: Ravi Shankar Chaudhary
Moderator- Yashwant Goud

2. • MR No. P665641
• 40 year old
• Male
• Resident of Maharashtra
• Born of a non-consanguineous marriage
• Presented on March 21, 2012
Patient data

3. • Outward Protrusion of eyeball OU (OS > OD)
since 2 year.
• Diplopia OU since 15 days
• Redness OU since 2 months
• Sometimes mild pain OU
Chief complaints

4. • No h/o previous ocular disease or surgery and
using glasses.
• H/o hyper thyroidism since September 2010
• No h/o HTN,DM, and ocular allergy
Past history

5. • Tab methimazole 5mg since 1-2 years
Current medication

6. March 21, 2014 OD OS
Distance VA
(Unaided)
20/30 20/20
VA (PH) 20/20 20/20
Near(Unaided) N8 @30 cm with EC N8 @30 cm with EC
Flash Retinoscopy ±/- 0.75x90 Plano
Acceptance ±/-0.5x90(20/20) Plano(20/20)
Near(+1.0) N6 @30 cm with EC N6 @30 cm with
EC
IOP 12mmHg@1.30 pm 12mmHg @1.30pm
Ocular examination

7. February 26, 2014 OD OS
EOM Elevation +
depression
restriction
Elevation +
depression
restriction
Lids UL+LL retraction UL+LLretraction
Conjunctiva Congestion with
dilated episcleral
vessels
Congestion with
dilated
episcleral
Ocular examination
lid
retraction

8. February 26, 2014 OD OS
PFH 17mm 19mm
MRD 05mm 06mm
Hertel’s(100 ) 24mm 26mm
Scleral show
(inferiorly+superiorly)
03mm + 04 mm 04mm + 04 mm
Lagophthalmos 01mm 03mm
Colour vision WNL WNL
Schimer’s 1 32mm 17mm
Fundus OU Retina
attached
C:D 0.3:1 ,HNRR
No e/o disc
edema /pallor
C:D 0.3:1
,HNRR
No e/o disc

9. PFH
MRD1
Laophthalmos

10. Function and application of the hertel mirror
exophthalmometer

11. Differential diagnosis
• VEIIN +miscellaneous
– Vascular
– Endocrine
– Infection
– Inflammation
– Neoplastic
– Miscellaneous

12. Diagnosis
Thyroid eye disease(active)

13. Plan of Management
1. CT-scan orbit
2. Plan orbital decompression(OS-OD)
3. LPS recession(OU)

14. Advice
1. Clinical photos
2. CT-scan orbit
3. Continue thyroid medication
4. Glasses
5. RTC 3/12

15. Follow up after 3/12
May 11, 2012 OD OS
Aided vision 20/20,N6(@30c
m)
20/20,N6(@30cm
)
Cornea Clear Clear
AC PACD>1/2CT PACD>1/2CT
Iris No NVI/PXF No NVI/PXF
Pupil R/R/R No RAPD R/R/R
Lens Clear Clear
Colour vision WNL WNL
Hertel’s(100) 24mm 26mm

16. CT-scan
1. OU axial proptosis
2. OU all EOMs grossely thickened mainly
superior rectus and inerior rectus
3. Increased fat spaces
4. No optic nerve compression seen.

17. Advice
1. Schedule OS 3 wall decompression under
general anesthesia

18. Post op day 1
May 11, 2012 OD OS
VA (unaided) 20/30-20/20 20/40
Cornea Clear Minimal
oedema
conjunctiva quiet Congestion
AC PACD>1/2CT Hazy/quiet
Pupil R/R/R R/R/R
Suture N/A Intact
Wound N/A Healthy

19. Advice
1. Admit today
2. OS Ciplox e/d BD
3. OS Betameth e/d (6-4-3-2-1)
4. Tab combiflam BD
5. Clean wound with 5% betadine BD
6. OS Toba e/d Q4H
7. Exocin e/o BD
8. Refresh tears e/d QiD
9. RTC tomorrow with CECC 2 OPD

20. May 12, 2012 OD OS
VA (unaided) 20/30-20/20 20/40-NI
Cornea Clear Minimal
oedema
conjunctiva quiet Congestion
AC PACD>1/2CT PACD >1/2
CT/Hazy view
Pupil R/R/R R/R/R
Suture N/A Intact
Wound N/A Healthy
Review # day 1

21. Review # 6 weeks
Sub :- Has came for right eye surgery as advised
June 28, 2012 OD OS
VA (with PGP) 20/20 20/20
Cornea Clear Minimal
oedema
conjunctiva quiet quiet
AC PACD>1/2CT PACD >1/2 CT
Pupil R/R/R R/R/R
Suture N/A Removed
Wound N/A Healed

22. June 28, 2013 OD OS
Aided vision 20/20(N6@30cm) 20/20(N6@30c
m)
Lid UL retraction with
lateral flare
UL retraction
with lateral flare
Cornea Clear Clear
Hertel’s(100) 24mm 19mm
Lagophthalmos 01mm Nil
Colour vision WNL WNL
EOM movements restriction
elevation and
depression
Mild restriction
elevation and
depression

23. Right eye decompression was performed after 1
weeks and advised same treatment as in the other
eye

24. After 1 months
September 04, 2013 OD OS
Aided vision 20/20(N6@30cm) 20/20(N6@30c
m)
Lid UL retraction with
lateral flare
UL retraction
with lateral flare
Cornea Clear Clear
Hertel’s(100) 18mm 19mm
Lagophthalmos Nil Nil
Colour vision WNL WNL
EOM movements Mild restriction Mild restriction

25. 1.Clinical photos
2. LPS recession as per patient wish
3. RTC SOS
Advice

26. Thyroid disorders
• Hyper thyroidism
• Hypo thyroidism
• Euthyroidism

27. Is the TED and Grave’s eye disease is same or
different
If eye Is involved with thyroid dysfunction then
it is termed as graves ophthalmopathy or
thyroid eye disease

28. Differential signs
Thyroid disorders Thyroid eye disease
1. Weight loss 1. Lid retraction
2. Low/high body temperature 2. Proptosis
3. Loss of hairs 3. Dryness
4. Tremor 4. Lagophthalmos
5. Conjunctival Congestion

29. Different signs
1. Dalrymple’s sign:- Widened palpebral fissure height
2. Von graefe’s sign:- Lid lag in primary gaze
3. Jelink’s sign:- Hyper pigmentation of lid
4. Rosenbach’s sign:- Tremor of the lid
5. Stellwag’s sign:- Rare blinking
6. Griffith’s sign/kocher’s sign:- Lid lag lower lid while looking upward

30. Thyroid Eye Disease
Active Inactive

31. TED is a unique autoimmune disease

32. Differentiating‘Active
from ‘Inactive’disease is the first step in the
management of TED
1

33. Clinical Activity Score
(Mourits et al)
1. Spontaneous retrobulbar pain
2. Pain on eye movement
3. Eyelid redness
4. Swelling: Eyelids
5. Conjunctival redness
6. Conjunctival Chemosis
7. Swelling: Caruncle
8. Worsening of Proptosis (3 mth)
9. Worsening of EOM
10. Worsening visual acuity (3 mth)

34. Clinical Activity Score
(Mourits et al)
1. Spontaneous retrobulbar pain
2. Pain on eye movement
3. Eyelid redness
4. Swelling: Eyelids
5. Conjunctival redness
6. Conjunctival Chemosis
7. Swelling: Caruncle
8. Worsening of Proptosis (3 mth)
9. Worsening of EOM
10. Worsening visual acuity (3 mth)

35. Clinical Activity Score
(Mourits et al)
1. Spontaneous retrobulbar pain
2. Pain on eye movement
3. Eyelid redness
4. Swelling: Eyelids
5. Conjunctival redness
6. Conjunctival Chemosis
7. Swelling: Caruncle
8. Worsening of Proptosis (3 mth)
9. Worsening of EOM
10. Worsening visual acuity (3 mth)

36. Clinical Activity Score
(Mourits et al)
1. Spontaneous retrobulbar pain
2. Pain on eye movement
3. Eyelid redness
4. Swelling: Eyelids
5. Conjunctival redness
6. Conjunctival Chemosis
7. Swelling: Caruncle
8. Worsening of Proptosis (3 mth)
9. Worsening of EOM
10. Worsening visual acuity (3 mth)

37. All ‘angry eyes’ in TED do not imply Active
phase
2

38. Pathogenesis

39. Routine Imaging is
NOT required for the diagnosis of TED
(and measurements do not provide any
additional information)
3

40. Imaging is required ONLY for
1.Suspected nerve compression
2.For surgical planning
3.When diagnosis is suspected

41. Investigations
• Vision
• Color vision
• Complete ocular examination (CAS)
• Exophthalmometry
• Pupil examination
• Schirmer’s test

42. Thyroid Eye Disease
1. Identifying Active Disease
2. Investigations
3. Management of Active Disease
4. Management of Stable Disease

43. Management of TED
• Mild disease: 90%*
• Explain Natural history
• Lubricants
• Sleep with head end raised
• Maintain Euthyroid State
* Perros P, Clin Endocrinol, 1995

44. Management of the Thyroid Gland
HYPER
• Anti-thyroid medications
• Radioactive Iodine
• Thyroid Surgery
HYPO
• Thyroxin
Which form of Therapy is associated with Eye Disease?

45. Compresive Optic Neuropathy
• Medical Management
• Surgical Management

46. The goal of medical treatment is to use
appropriate therapy until the patient reaches the
inactive stage
4

47. Thyroid Eye Disease
1. Identifying Active Disease
2. Investigations
3. Management of Active Disease
4. Management of Stable Disease

48. Surgical Paradigm
• Decompression
• Strabismus
• Eyelid Surgery
• Cosmesis

49. Surgical treatment is performed in the
inactive stage
5

50. Orbital Decompression
• Expansion of the orbital volume by
- Bony expansion
- Fat removal

51. Orbital Decompression

52. Message home
– Eyelid retraction is the most common feature of
TED
– TED is the most common  uni/bilateral proptosis,
markedly asymmetric
– 90% hyper, but 6% euthyroid
– Severity is not parallel to serum level (TSH, T3,
T4..), but the smoking indeed 7x
– Urgent care may be require for CON, severe
proptosis  cornea decompensation
– Surgery should be in order: Orbital decompression
 Strabismus  eyelid correction

53. Acknowledgement
Dr milind naik for photography and
review literature
Mr yashwant and winston for
guidance
Rohit,krishna ,saikat and niranjan for
suggestions and animations
Whole plasty
group for
encouragement

54. L V Prasad Eye Institute
www.lvpei.org
Excellenc Equity Efficiency
Thank you!