III- C1-8MATEMATICO MATIAS MAULION

MEDENILLA MEDINA, K. MEDINA, S.

SALIENT FEATURES

75 year-old, Male CC: Blurring of Vision Visual Acuity: 20/50 OD 20/400 OS Bilateral Hyperemic Conjunctiva (+) Afferent Pupillary Defect OS Minimal Lens Opacity Palpitations Tearing

Diagnostic Tools

Serum TSH Serum Free T4 & T3 Tests for antibodies

Anti-thyroglobulin Anti-microsomal Anti-thyrotropin receptor

Orbital Imaging Ultrasound CT Scan

Serum TSH, Free T4 & T3 For screening for thyroid disease Highly sensitive and specific

Serum TSH useful to establish a diagnosis of

hyperthyroidism or hypothyroidism

Blood Assays TRAb (thyroid receptor antibody), TBII

(TSH-binding inhibitor immunoglobulin), and LATS (long-acting thyroid stimulator) assays Measure the binding of TSH to a solubilized

receptor TSI (thyroid-stimulating immunoglobulin)

assays Measure the ability of immunoglobulin G

(IgG) to bind to the TSH receptor on cells and to stimulate adenylate cyclase production

Blood Assays Antithyroid antibody test

antithyroglobulin test Thyroid peroxidase test

also called the antimicrosomal antibody test and the antithyroid microsomal antibody test.

Thyroid peroxidase antibodies and antibodies to thyroglobulin Useful when trying to associate eye findings

with a thyroid abnormality, such as euthyroid Graves disease.

Orbital Imaging Ultrasound

Quick confirmation of thickened muscles or an enlarged superior ophthalmic vein.

CT scan and MRI Reveals thick muscles with tendon sparing and

dilated superior ophthalmic vein Apical crowding of the optic nerve MRI is more sensitive for showing optic nerve

compression. CT scan is performed prior to bony

decompression because it shows better bony architecture.

Relative Afferent Pupillary Defect one of the most important assessments to

make in a patient complaining of decreased vision is whether it is due to an ocular problem or to a potentially more serious optic nerve problem

usually a sign of optic nerve disease may also occur in retinal disease not occur in media opacities (corneal

disease, cataract, and vitreous hemorrhage)

Swinging Flashlight Test

a light is alternately shone into the left and right eyes

NORMAL response equal constriction of both pupils,

regardless of which eye the light is directed at

intact direct and consensual pupillary light reflex

Swinging Flashlight Test

AFFERENT PUPILLARY DEFECT light shone in the affected eye will produce

less pupillary constriction than light shone in the unaffected eye

light directed in the affected eye will cause only mild constriction of both pupils decreased response to light from the afferent

defect light in the unaffected eye will cause a

normal constriction of both pupils intact afferent path and an intact consensual

pupillary reflex

Afferent Pupillary Defect Optic Nerve Lesion

the pupillary light response (the direct response in the stimulated eye and the consensual response in the fellow eye) is less intense when the involved eye is stimulated than when the normal eye is stimulated

Orbital disease• compressive damage to the optic nerve from thyroid related orbitopathy• compression from enlarged EOM in the orbit

Other Optic Nerve Disorders Optic neuritis Ischemic optic neuropathies

arteritic (Giant Cell Arteritis) and non-arteritic causes

loss of vision or a horizontal cut in the visual field Glaucoma

if one optic nerve has particularly severe damage Traumatic optic neuropathy

direct ocular trauma, orbital trauma, and even more remote head injuries which can damage the optic nerve as it passes through the optic canal into the cranial vault

Other Optic Nerve Disorders Optic nerve tumor

primary tumors of the optic nerve (glioma, meningioma)

tumors compressing the optic nerve (sphenoid wing meningioma, pituitary lesions)

Radiation optic nerve damage Optic nerve infections or inflammations

Cryptococcus, Sarcoidosis, Lyme disease Surgical damage to the optic nerve

GOALS

Regulation of Thyroid Hormones

Avoid Corneal Damage Reduce Inflammation Orbit Decompression

Regulation of Hormones

Refer the patient to Endocrinologist Anti-Thyroid Hormones

PTU, Methimazole, Carbimazole

Avoid Corneal Damage

Topical lubrication of the ocular surface

Tarsorrhaphy Alternative option when the

complications of ocular exposure can't be avoided solely with the drops

Reduce Inflammation

Corticosteroids Efficient in reducing orbital

inflammation Benefits cease after discontinuation Limited because of many side effects

Radiotherapy Alternative option to reduce acute

orbital inflammation Controversial due to its efficacy

Reduce Inflammation

Smoking cessation A simple way of reducing

inflammation as pro-inflammatory substances are found in cigarettes.

Orbit Decompression

Surgery To improve the proptosis and

address the strabismus causing diplopia

Stable patient for at least 6 months

Urgent: To prevent blindness from optic nerve compression

Orbit Decompression

Eyelid Surgery Most common surgery performed

on patients with Grave’s Ophthalmopathy

Lid lengthening Surgery Done on upper and lower eyelid To correct the patient’s

appearance and ocular surface symptoms

Orbit Decompression

Marginal Myotomy Levator Palpabrae muscle Reduce palpebral fissure height by 2-3 mm

Lateral Tarsal Canthoplasty Performed with Marginal Myotomy of

Levator Palpebrae In a more severe upper lid retraction or

exposure keratitis Lower the upper eyelid by as much as 8

mm

Orbit Decompression

Mullerectomy Resection of Muller muscle

Eyelid Spacer Grafts Recession of Lower Eyelid

Retractors Blepharoplasty

To debulk the excess fat in the lower eyelid

TO MICH!

NING, UNG TREATMENT PO AFTER THIS SLIDE IS FROM GELYN

UNG TREATMENT BEFORE THIS SLIDE IS FROM ME… KAW NA BAHALA MAGMIX… MEJO SAME SAME LANG NAMAN…

Treatment

Short term goal: To conserve useful vision

Long term goal: To restore the orbital anatomy

Glucocorticoids Rationale: Immunosuppressive and anti-

inflammatory Decrease the production of

mucopolysaccharides by the fibroblasts methylprednisolone 1 g every other day

for 3 cycles

SE: immunosuppression, hyperglycemia, osteoporosis, necrosis, weight gain, Cushing syndrome

Orbital radiation Rationale: Anti-inflammatory;

radiosensitivity of activated orbital T cells and fibroblasts

Cumulative dose of radiation: 20 Gy per eye, fractionated over a 2-week period

SE: radiation retinopathy, cataract

Orbital decompression at least 2 orbital walls usually are

decompressed (traditionally, the medial wall and floor of the orbit).

Medial decompression for compressive neuropathy must be taken posteriorly all the way to the apex of the optic canal.

Surgery can be approached from a transorbital or trans-sinus route.

Strabismus surgery Inferior rectus muscle recession may

decrease upper lid retraction, but it often results in lower lid retraction despite dissection of the lower lid retractors.

Because the inferior rectus muscle has subsidiary actions (excyclotorsion and adduction), inferior rectus muscle recessions may lead to a component of intorsion and A-pattern strabismus.

Lid-lengthening surgery 2-3mm of upper lid retraction can be

ameliorated with a Müller muscle excision.

Lateral levator tenotomy is often helpful to decrease the temporal flare.

If further amounts of lid recession are required, levator recession can be considered.

Lower lid-lengthening usually requires a spacer material.

Blepharoplasty Lower lid blepharoplasty can be

approached transconjunctivally if no excess lower lid skin is present

Upper lid blepharoplasty is performed transcutaneously with conservative skin excision.

Brow fat resection may be considered. Dacryopexy may be required if lacrimal

gland prolapse occurs.