Exophthalmos

Exophthalmos

1. EXOPHTHALMOS

2. PROPTOSIS Forward displacement of the eyeball beyond the line joining the superior and inferior orbital margin. EXOPHTHALMOS It is the same thing. But it is reserved for Thyroid eye disease.

3. THYROID EYE DISEASE

4. Thyroid eye disease (TED) : -lid retraction -lid lag - proptosis Endocrine exophthalmos , Malignant exophthalmos , Dysthroid ophthalmopathy , Occular Graves’s disease (OGD), Graves ophthalmopathy (GO).

5. Etiopathogenesis Hyperthyroidism (90%) Hypothyroidism (4%) Euthyroidism (6%)

6. Risk factors Female (4-6 times) Smoking Middle age Autoimmune thyroid ds . HLA-DR3, HLA-B8

7. Pathogenesis

8. Classification 1. American thyroid association (ATA)

9. Case 45/F Recurrent grave thyrotoxicosis Smoker TSH 0.03 mu/L , FT4=34 pmol /L Red eye, excessive sweating , squint and double vision.

10. Clinical features Lid signs - Dalrymple sign (retraction of upper lids giving staring and frightened apperance ) - mc and earliest feature

11. Von Graefe’s sign ( when eye globe is moved downward, the upper lid lags behind)

12. Enroth’s sign ( fullnes of eye due to edema )

13. Gifford’s sign (difficulty in eversion of upper lid)

14. Stellwag’s sign (infrequent blinking)

15. Jellinek’s sign ( increase pigmentation of the lids)

16. 2. Conjuctival signs deep injection chemosis 3. Pupillary signs ineqquality of dilatation of pupils

17. Clinical course 1. Congestive or active phase 2. Fibrotic or inactive phase

18. Differential diagnosis Orbital cellulitis Idiopathic orbital inflammatory disease Sarcoidosis Amyloid

19. Investigation

20. Investigation Thyroid function test Thyroid autoantibody assay Usg Ct scan MRI

21. MANGEMENT

22. Management Periodic clinical work up Non-surgical Surgical

23. a.) Periodic clinical work up

24. Non-surgical Smoking cessation Head elevation (night) and cold compression (morning) Artificial tear Eyelid taping Guanethidine 5% eye drop Systemic steroid Radiotherapy Combined therapy

25. Surgical During active phase orbital decompression During inactive phase extraoccular and eyelid Sx .

26. Orbital decompression Two wall Three wall Four wall 1.)Orbital floor 2) Medial wall Add roof(lat. Half) and sphenoid at apex. Add Lateral wall

27. Extraocular surgery Recession surgery is done Mc= inferior rectus recession

28. Eyelid surgery Mullerectomy - Levator recession- Scleral graft with LPS- Blepharoplasty -

29. Summary