A multidisciplinary (MDT) approach to Graves Orbitopathy (GO) Thyroid Eye disease (TED)

Graves Orbitopathy (GO)
Thyroid Eye disease (TED) the most common inflammatory disease of the
orbit
One patient’s journey 40+ year old NIDDM
Asian lady
Graves Hyperthyroidism
2014 Thyroidectomy
constant double vision
Euthyroid Post thyroidectomy
sudden loss of vision
pain and double vision
MRI orbit to
Sight Threatening disease left eye Day 2
3 days of high dose intravenous steroids in
Endocrine Day Unit
Day 6 Eye Clinic review
Decision for urgent decompression
No Radiotherapy due to
Monthly review in MDT Thyroid eye clinic
with immunosuppression eye clinic Ongoing Rx
Day 1
pain proptosis
constant double vision
constant double vision
ongoing immunosuppression with mycophenolate
Decreasing vision increasing pain
Switched to prednisolone & ciclosporin to try to maintain her vision
Poorly controlled diabetes, diabetic eye disease
not suitable for radiotherapy
relevant GO
control
vision
severity
Learning Outcomes
2 Risk Factors and how to modify them
3 Principles of management of Thyroid Eye Disease (including TEAMed 5 )
4 A case study to illustrate the need for a multidisciplinary approach
Aetiology & Pathogenesis
Graves Disease
hyperthyroidism
Tc NM scan
Pathognomonic features, eye
disease, thyroid bruit
Estimated Prevalence of GO
1 in 10 will not have any thyroid hormone problems
of these about half will go on to have thyroid hormone problems
about 1 in 10 will only be affected in one eye socket
family history
thyroid control
12
• Higher relapse rate on stopping anti-thyroid drugs
• x4 GO progression post I-131
• poorer response to immunosuppression
important to render euthyroid
40%
Do not give radio-iodine if
there is significant eye
oral steroids
The disease does ‘burn out’
Lasts on average 1 yr in non smokers 2-3 yrs smokers
Reactivation 5-10%
Rundle’s Curve
Lid retraction ≥ 2mm
involvement
Minor lid retraction
EUropean Graves Orbitopathy GrOup clinical classification
GO is self limiting disease but you need to ask for every patient which severity curve are they on ?
where are they on their disease course?
20
28% had other co-morbidities causing poor vision
25% CAS <3
33% no proptosis
21
Management
• halving the time
for optimal treatment of thyroid
disease
significant eye disease requiring
rapid treatment of post RAI hypothyroidism
mitigates risk in patients with low risk of GO /
mild GO
months), time from first
UK Multicentre audit (Orbit
Not enough ophthalmolgists work in thyroid Eye
MDT clinics in the UK
There are not enough clinics to accommodate
this recommendation
Number of ophthalmologists BOPSS surveyed who work in Thyroid MDT clinic
Endocrinologist
Squint
@ Western Eye Hospital (since 2015)
@ Charing Cross Hospital (starting Jan 2018)
MDT Clinic
acute stage
Ulceration or infection of the cornea
Rehabilitation
Generally post thyroidectomy
to expand the orbital volume
to ease pressure or allow
tissues to settle back into the
orbit
35
35 35
36
an interdisciplinary thyroid-eye clinic in Germany
reports significant occupational disability
28% were disabled
3% had lost their jobs Ponto et al 2009
Many GO patients are unhappy and
this may not reflect our clinical
impressions of disease activity /
38 38
treating TED in
Rehabilitation Surgery improves QOL