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Thyroid eye

1. Thyroid Orbitopathy

2. ILOs: * Definition of TAO * Stages of TAO * Ocular manifestations * Classification * Differential Diagnosis * Medical and Surgical Treatment

3. Definition : Thyroid-associated orbitopathy (TAO ) is inflammatory disease of the orbit often occurs with systemic thyroid imbalance (Graves Disease) which is part of an autoimmune process that can affect the orbital and periorbital tissue. Although the terms Graves ophthalmopathy , thyroid ophthalmopathy , and thyroid eye disease

4. Diseases associated with TAO : Thyroid-associated orbitopathy is f requently associated with Graves disease , and the vast majority of patients are hyperthyroid . A systematic review of the world literature found that in patients with (TAO) 10% were hypothyroid (Hashimoto Thyroiditis )and 8% were euthyroid .

5. Risk Factors : 1-increased age of onset , duration of Graves hyperthyroidism 2- smoking .

6. Stages of TAO : 1-Congestive "inflammatory" Active stage : - cellular infiltration - Proptosis - Optic nerve compression - Hypertrophy of EOMs 2-fibrotic "Quiescent" stage : Fibrosis of EOMs lead to limitation of movement and diplopia

7. Ocular manifestations: Lid retraction : due to overaction of Muller’s muscle Signs of Lid retraction : 1-Von Graefe’s sign : Upper lid lags on downward movements of the eyeball. 2-Stellwag’s sign (Kocher’s sign) :There is infrequent and incomplete blinking.

8. Von Graefe’s sign :

9. Stellwag’s sign (Kocher’s sign) :

10. Conjunctival hyperemia over the insertion of Lateral rectus and medial rectus muscles (sign of disease activity) Kerato -conjunctivitis sicca (Dry Eye) due to lacrimal gland infiltration Soft tissue involvement

11. Proptosis : protrusion of the globe Characters : permenant (70%) and Bilateral in sever proptosis exposure keratitis may occure Swelling : Perirbital and lid due to edema and infiltration

12. Restrictive myopathy causing diplopia (double vision ) Compressive optic neuropathy Lead to : Decrease visual acuity Color vision affected Fundus Disc swelling Marcus Gunn pupil

13. Classification: Numerous classification systems for (TAO ) exist : 1- Types I and II 2- NOSPECS : NOSPECS uses a mnemonic to describe the presence or absence of signs or symptoms 3- EUGOGO (European Group of Graves' Orbitopathy) or VISA (vision, inflammation, strabismus, and appearance) classification most used now.

14. Differential Diagnosis 1-Orbital and preseptal cellulitis : patient has evidence of infection ( eg , fever, leukocytosis ). On neuroimaging , paranasal sinuses often opacification

15. 2-carotid cavernous fistula : the patient may have a cranial bruit , and the dilated episcleral vessels extend to the limbus . Differential Diagnosis

16. 3- Orbital inflammatory syndrome (orbital pseudotumor ): more painful and associated more often with ptosis than lid retraction Differential Diagnosis

17. 4-Dorsal midbrain syndrome ( Parinaud syndrome) : lid retraction and upgaze problems . In contrast to thyroid-associated orbitopathy , the globes in Parinaud syndrome elevate on the doll's head maneuver and the eye tends not to be injected or proptotic Differential Diagnosis

18. Medical Treatment : 1-Protect cornea from exposure 2-The traditional treatment options for moderate to severe thyroid-associated orbitopathy includ glucocorticoids , orbital radiation .   3- Teprotumumab is a relatively new targeted medication For moderate to severe thyroid-associated orbitopathy , but it is expensive and unavailable in some countries

19. Surgical Treatment: The surgical operations are done in following order 1- For proptosis and compressive optic neuropahy : orbital decompression 2- For squint : squint surgery 3- For lid retraction : lid lengthening

20. Names: