Things That Changed How I Manage Graves PPT Small

Anthony DeWilde, OD FAAO

Kansas City VAMC

Six Things That Changed How I Manage Graves’

Disease

Tuesday, April 23, 13

1. Thyroid status 2. Pathogenesis3. Ocular signs/symptoms4. Labs5. Smoking6. Mental Health

6 Things


Autoimmune

Affects:SkinThyroid OrbitPsych

Graves’ Disease


What Graves' Is Not

NOT a Thyroid disease

It IS autoimmune affecting

Skin

Orbit

Thyroid

Psych


Also goes by! Thyroid Associated Ophthalmopathy! Thyroid Eye Disease! Graves’ Ophthalmopathy! Graves’ Dysthyroid Ophthalmopathy

Graves’ Disease


Pretibial myxedema (1-4%)

Skin


80% are HyperthyroidSweat, tremor, weight loss

10% are HypothyroidCold, weight gain, hair loss

10% are Euthyroid

Thyroid

Best Practice & Research Clinical Endocrinology & Metabolism 26 (2012) 273-279


30-50% of Graves’ patients have orbitopathy

2-5% serious complications

Orbit



Psych

Affects up to 1/3 of Graves' patients

Attention

Mood

Anxiety

Archives of Ophthalmology. Vol 123:491-496. April 2005.


Graves' Manifestations

0

23

45

68

90

Skin Psych Orbit Thyroid


Untreated Graves'Can lead to

Heart problems

Fragile bones

Psychotic changes

Pregnancy complications

Coma

Death


Graves’

OrbitThyroid

Vicious Cycle


Increased antithyroid antigensTSH receptor antibodiesIncreased T3, T4Decreased TSH

Autoimmune



Increase inCD4CD8B cellsMacrophages

Autoimmune


Increase inFibroblastsHyaluronic AcidCollagenAdipose

This leads to further inflammation

Autoimmune

N Engl J Med 362:726-38. Feb 2010.

Survey of Ophthalmology. Vol 55: 215-225, May 2010.


May come to office with diagnosis

How do we diagnose new Graves’ Disease?AppearanceSymptomsLabsImaging

Diagnosis


Stare Eyelid retraction

Up to 90% of patientsCaruncle, eyelid edemaCaruncle, eyelid, conjuntival rednessRarely: optic nerve disease Edema Atrophy Glaucoma

Appearance


Optic Nerve Compression


Optic Nerve Compression

Ophthalmology 2012;119:2174–2178




Exophthalmos

HertelAsian upper limit = 18White upper limit = 21Black upper limit = 24

Appearance



Dry eye

Ache – rest or movement

Blur

Diplopia

Symptoms


Free T3 and T4

TSH

Anti-thryoglobulin (TSI)

Thyrotropin-Binding Inhibitory Immunoglobulin (TBII)

Refer to Endocrine

Labs


CT allows measurement of Orbital fatLacrimal glandExtraocular muscles

Have to get before orbital decompression

Imaging


MRIBetter soft tissue evaluationBest to monitor seriallyPreferred imaging strategy

Imaging


NO SPECS

VISA

EUGOGO

Classification


Not beneficialGrading is loosely definedDoes not document progression wellLittle insight into function or treatment

NO SPECS


Vision/Optic NeuropathyInflammation/congestionStrabismus/motilityAppearance/exposure

Descending order of importanceEasier documentation

VISA


EUropean Group of Graves’ Orbitopathy

Similar to VISA

Extensive documentation

EUGOGO


Stabilize Thyroid if necessaryThyroid medicationThyroidectomyRadioactive iodine therapy

Thyroid Treatment


Thyroidectomy has never been proven effective

Radioactive iodineCan exacerbate orbitopathy in 20%Need 6 week low dose steroid

Medication Anti-thyroid meds Thyroid replacement meds

Thyroid Treatment


Other Systemic Tx

May use Beta Blockers

Controls symptoms


If Graves’ is active (usually lasts 6-18 mo)Oral and/or IV steroidStabilize inflammationPrevent further swelling

Ophthalmic Treatment


Lubrication

SurgeryOrbital decompressionStrabismusEyelid retraction

Ophthalmic Treatment


Treat dry eye

Treat exposure keratopathy

Consider ointment qhs if lagophthalmos

Lubrication


Stabilize first

Not first line

Must perform if optic nerve damage

Strabismus is a common side effect (up to 60%)

Orbital Decompression

Ophthalmology. Vol 101; 223-230. 1994

Ophthalmology. Vol 101; Num 5; 938-42. May 1994.


Stabilize first

May try prism first

Strabismus


Relaxation of levator

Helps with cosmesis and symptoms

May need re-operation (up to 25%)

Eyelid Retraction


ReviewSkin

Thyroid

Psych

Eye

Exophthalmos/Lagophthalmos

Dry eye

EOM/Diplopia/Pain

Compressive Optic Neuropathy

Glaucoma


Goals for ManagementActive

Stabilize - Thyroid & Inflammation

Comfort

Optic Nerve

Inactive

Comfort

Monitor


High rate of depression

Need to consider quality of life

Psychiatric Treament


Endocrinologist

Primary Care

OphthalmologyNeuroPlastics

Mental Health

Team Approach


Worse progressionWorse prognosis

Study:Non-smokers - 61/65 (94%) benefited from TxSmokers - 58/85 (68%) benefited from Tx

Smoking

Best Practice & Research Clinical Endocrinology & Metabolism 26 (2012) 371-379.


1. Thyroid status 2. Pathogenesis3. Ocular signs/symptoms4. Labs5. Smoking6. Mental Health

6 Things


Patient Example

50 year old male

Complains of:

! Diplopia

! Swollen Eyelid OS

! Red Eye OS


Exam

20/25 OD and OS

IOP 18/18

No APD

Diplopia in lateral and downgaze

Pain in lateral gaze



Exam

Exophthalmos OS

! Hertel 19/23

Lagophthalmos

Conjunctival edema and injection

Eyelid edema


Labs

TSH = 0.003 (normal = 0.47-5.00)

T4 = 20.3 (normal = 4.5-12)




Referral

Endocrine

Oculoplastics

Inform PCP of findings


5 months later

IOP 18/24

? APD OS

Start IOP Timolol 0.5%

Start Oral Pred (40 mg)




6 months later

IOP as high as 38/28

Oral Pred now 80 mg

+ APD OS

IOP 19/19 on Travatan, Cosopt, Alphagan

Refer for Orbital Decompression


After Orbital Decompression

Develops Diplopia

But...IOP 12/14 on meds


Last month

Now S/P:

! Orbital Decompression

! Strabismus Surgery

! Eyelid Retraction

Now has 20/80 cataract


Thank [email protected]


mailto:[email protected]

mailto:[email protected]

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Things That Changed How I Manage Graves PPT Small