things that changed how i manage graves ppt small
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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
Tuesday, April 23, 13
What Graves' Is Not
NOT a Thyroid disease
It IS autoimmune affecting
Skin
Orbit
Thyroid
Psych
Tuesday, April 23, 13
Also goes by! Thyroid Associated Ophthalmopathy! Thyroid Eye Disease! Graves’ Ophthalmopathy! Graves’ Dysthyroid Ophthalmopathy
Graves’ Disease
Tuesday, April 23, 13
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
Tuesday, April 23, 13
30-50% of Graves’ patients have orbitopathy
2-5% serious complications
Orbit
Best Practice & Research Clinical Endocrinology & Metabolism 26 (2012) 273-279
Tuesday, April 23, 13
Psych
Affects up to 1/3 of Graves' patients
Attention
Mood
Anxiety
Archives of Ophthalmology. Vol 123:491-496. April 2005.
Tuesday, April 23, 13
Untreated Graves'Can lead to
Heart problems
Fragile bones
Psychotic changes
Pregnancy complications
Coma
Death
Tuesday, April 23, 13
Increased antithyroid antigensTSH receptor antibodiesIncreased T3, T4Decreased TSH
Autoimmune
Tuesday, April 23, 13
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.
Tuesday, April 23, 13
May come to office with diagnosis
How do we diagnose new Graves’ Disease?AppearanceSymptomsLabsImaging
Diagnosis
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Stare Eyelid retraction
Up to 90% of patientsCaruncle, eyelid edemaCaruncle, eyelid, conjuntival rednessRarely: optic nerve disease Edema Atrophy Glaucoma
Appearance
Tuesday, April 23, 13
Exophthalmos
HertelAsian upper limit = 18White upper limit = 21Black upper limit = 24
Appearance
Best Practice & Research Clinical Endocrinology & Metabolism 26 (2012) 249-258
Tuesday, April 23, 13
Free T3 and T4
TSH
Anti-thryoglobulin (TSI)
Thyrotropin-Binding Inhibitory Immunoglobulin (TBII)
Refer to Endocrine
Labs
Tuesday, April 23, 13
CT allows measurement of Orbital fatLacrimal glandExtraocular muscles
Have to get before orbital decompression
Imaging
Tuesday, April 23, 13
MRIBetter soft tissue evaluationBest to monitor seriallyPreferred imaging strategy
Imaging
Tuesday, April 23, 13
Not beneficialGrading is loosely definedDoes not document progression wellLittle insight into function or treatment
NO SPECS
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Vision/Optic NeuropathyInflammation/congestionStrabismus/motilityAppearance/exposure
Descending order of importanceEasier documentation
VISA
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EUropean Group of Graves’ Orbitopathy
Similar to VISA
Extensive documentation
EUGOGO
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Stabilize Thyroid if necessaryThyroid medicationThyroidectomyRadioactive iodine therapy
Thyroid Treatment
Tuesday, April 23, 13
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
Tuesday, April 23, 13
If Graves’ is active (usually lasts 6-18 mo)Oral and/or IV steroidStabilize inflammationPrevent further swelling
Ophthalmic Treatment
Tuesday, April 23, 13
Lubrication
SurgeryOrbital decompressionStrabismusEyelid retraction
Ophthalmic Treatment
Tuesday, April 23, 13
Treat dry eye
Treat exposure keratopathy
Consider ointment qhs if lagophthalmos
Lubrication
Tuesday, April 23, 13
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.
Tuesday, April 23, 13
Relaxation of levator
Helps with cosmesis and symptoms
May need re-operation (up to 25%)
Eyelid Retraction
Tuesday, April 23, 13
ReviewSkin
Thyroid
Psych
Eye
Exophthalmos/Lagophthalmos
Dry eye
EOM/Diplopia/Pain
Compressive Optic Neuropathy
Glaucoma
Tuesday, April 23, 13
Goals for ManagementActive
Stabilize - Thyroid & Inflammation
Comfort
Optic Nerve
Inactive
Comfort
Monitor
Tuesday, April 23, 13
Endocrinologist
Primary Care
OphthalmologyNeuroPlastics
Mental Health
Team Approach
Tuesday, April 23, 13
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.
Tuesday, April 23, 13
1. Thyroid status 2. Pathogenesis3. Ocular signs/symptoms4. Labs5. Smoking6. Mental Health
6 Things
Tuesday, April 23, 13
Patient Example
50 year old male
Complains of:
! Diplopia
! Swollen Eyelid OS
! Red Eye OS
Tuesday, April 23, 13
Exam
20/25 OD and OS
IOP 18/18
No APD
Diplopia in lateral and downgaze
Pain in lateral gaze
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Exam
Exophthalmos OS
! Hertel 19/23
Lagophthalmos
Conjunctival edema and injection
Eyelid edema
Tuesday, April 23, 13
5 months later
IOP 18/24
? APD OS
Start IOP Timolol 0.5%
Start Oral Pred (40 mg)
Tuesday, April 23, 13
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
Tuesday, April 23, 13
Last month
Now S/P:
! Orbital Decompression
! Strabismus Surgery
! Eyelid Retraction
Now has 20/80 cataract
Tuesday, April 23, 13
Thank you!anthony.dewilde@va.gov
Tuesday, April 23, 13
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