QuestionSBA
QuestionChoice
This patient has untreated hyperthyroidism and has symptoms suggestive of thyroid eye disease that has gone untreated, and her symptoms suggest optic nerve compression. It is important to treat her underlying thyroid disease, but as she has developed visual disturbance, surgical decompression should be considered as part of the acute treatment here
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a
Surgical decompression of the optic nerve
QuestionChoice
This patient has a history suggestive of thyroid eye disease and compression of the optic nerve; therefore, referring to an optician would not benefit her acute management
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c
Referral to an optician
QuestionChoice
Eye taping at night is beneficial if unable to close the eyelid to help prevent drying and abrasions whilst sleeping. Some patients with severe thyroid eye disease and very protuberant eyes may need assistance with lid closure; however, this intervention would not address the patient's visual loss
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d
Eye taping at night
QuestionChoice
Whilst patients with thyroid eye disease are at risk of dry eyes and developing conjunctivitis and abrasions; there is no evidence in this history of active infection that would require topical treatment
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b
Topical chloramphenicol
QuestionChoice
Laser eye surgery can correct refractive errors in vision; however, that is not the diagnosis here
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e
Laser eye surgery
QuestionComment
So the GP can sUrGiCalLy dEcoMpReSs the optic nerve???????
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QuestionComment
qs doen't imply this, it simply asks for the intervention likely needed. not the next best step
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Ale
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Embolism Transplant
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Poor answers lol 
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# Summary

Thyroid Eye Disease, also known as Graves' Ophthalmopathy, is a complex autoimmune condition closely associated with hyperthyroidism. It manifests with a range of ocular symptoms, including eyelid retraction, proptosis, double vision, and ocular discomfort. The disease primarily affects the orbital tissues and extraocular muscles due to an immune response targeting the thyroid gland and surrounding structures. Diagnosis relies on clinical evaluation, imaging, and thyroid function tests. Management encompasses medical therapy, supportive care, and in severe cases, surgical interventions to address disfiguring or vision-threatening complications. 

# Definition

Thyroid eye disease (TED) is a complication of Grave's disease, which is an autoimmune hyperthyroidism. An inflammatory process results in swelling of the extraocular muscles and orbital fat, which leads to multiple ocular complications.

# Pathophysiology

An idiopathic autoimmune inflammatory process is responsible for TED, the exact mechanism of which remains unclear. Evidence suggests that an autoimmune reaction to TSH receptors results in lymphocyte infiltration into orbital tissues, which initiates an inflammatory process.

The **inflammatory phase** of TED typically lasts 6–24 months and results in the swelling of extraocular muscles and orbital fat – it is only during this initial inflammatory phase that TED is responsive to medical management.

After the inflammatory phase, there is an **inactive fibrotic phase**, which is nonresponsive to medical therapy.

Hyperthyroidism and TED usually present within 18 months of each other, but each can be present in isolation.

# Epidemiology

- Roughly half of patients with Grave's disease develop TED
- 80% of cases of TED are due to Grave's disease

# Risk factors

- **Smoking** – the most important risk factor for development and increased severity of TED in patients with Grave's disease, so it is important to counsel patients on the importance of smoking cessation
- Family history of Grave's disease and other autoimmune disease
- Female sex
- Poor thyroid control


# Signs and Symptoms

- Ocular pain – often worse on movement
- Dry, red eyes
- 'Bulging eyes'
- Painful eyelids
- Proptosis/exophthalmos
- Lid retraction and lid lag
- Chemosis
- Orbital fat prolapse
- Exposure keratopathy

[lightgallery] 



# Management 

Early medical management of TED has the potential to stabilise, slow or even reverse the disease process. Good control of thyrotoxicosis is essential and other medical therapies, such as steroids or other immunosuppressants, may be used.

In sight-threatening TED, urgent surgical orbital decompression may be required, followed by intravenous corticosteroids.

Conservative therapy consists of artificial tears, ointments and prisms to help with the symptoms of dry eye and diplopia.

# Complications

Sight-threatening complications include:

- **Exposure keratopathy** – where corneal damage and infection occur as the patient is unable to close their eyes

- **Compressive optic neuropathy** – occurs when the retro-orbital swelling begins to compress on the optic nerve 
  - suspect this when signs of optic nerve involvement occur  – reduced visual fields, reduced colour vision, reduced visual acuity, relative afferent pupillary defect

- **Diplopia** – due to fibrosis of the extraocular muscles limiting gaze in various directions

# References

Denniston AK, Murray PI. Oxford Handbook of Ophthalmology. Fourth Edition. Oxford University Press. 2018.

[Click here for an in-depth review of TED on the Patient UK website](https://patient.info/doctor/thyroid-eye-disease-pro)

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A typical appearance of exophthalmos seen in a patient with grave's disease.
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Thyroid eye disease
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Thyroid eye disease can cause optic nerve compression, which may lead to vision impairment; surgical decompression is often required when visual disturbances or threat to vision become significant.
A 28-year-old female presents to her GP complaining that she struggles to read and has discomfort with eye movement. She has never had issues with her vision before. On examination, she is very slim with protuberant eyes and is flushed despite it being cold in the practice. She has significantly reduced visual acuity. She has no past medical history of note.

What intervention is likely to be indicated?
a