exopthalmus

TAO is an orbital autoimmune disease. The thyroid-stimulating hormone receptor (TSH-R) is

an antigen found in orbital fat and connective tissue, and is a target for autoimmune assault.
However, some patients with Graves orbitopathy present with neither anti-microsomal nor
anti-thyroglobulin nor anti-TSH receptor antibodies, the antibodies identified in Graves'
disease.
On histological examination, there is an infiltration of the orbital connective tissue by
lymphocytes, plasmocytes, and mastocytes. The inflammation results in a deposition of
collagen and glycosaminoglycans in the muscles, which leads to subsequent enlargement and
fibrosis. There is also an induction of the lipogenesis by fibroblasts and preadipocytes, which
causes orbital volume enlargement due to fat deposition. Thyroid eye disease affects between
25-50% of patients with Graves' disease.
TAO is an inflammatory disease of the orbital tissues. The effects of
inflammation, mediated through cytokine release, include proliferation of
fibroblasts, increased deposition of extracellular matrix, and adipocyte
differentiation and proliferation. As a result, edema, enlargement of the
extraocular muscles, and increased volume of the orbital soft tissues occur with
ensuing exophthalmos and, in some patients, compression of the optic nerve.
Edema, inflammation, and late fibrosis, account for the decreased function of the
extraocular muscles, despite relative preservation of the fibers themselves. The
recruitment of T cells to the orbits of these patients may result from the
expression of the target of the aberrant immune response in Graves' disease, the
TSH receptor, in the orbits of patients with TAO. The orbital fibroblasts, especially
those present within patients with TAO, may be more sensitive to the effects of
cytokines, accounting for the frequent, and relatively selective, involvement of
the orbit in Graves' disease. Insight into the cellular and molecular pathways
proposed in this cascade introduces potential sites for new therapeutic
approaches and understanding of the mechanisms of current treatments.
Corticosteroids, used frequently in the treatment of TAO, have a detectable effect
at the molecular level. While glucocorticoids do not directly influence
extracellular matrix production [62] or baseline proliferation of orbital fibroblasts
[27] they do attenuate the effect of several cytokines on inducing proliferation of
these fibroblasts or extracellular matrix production, and this influence is greater
in fibroblasts from TAO patients [27,36]. The consistent observation of early
inflammation suggests that immunomodulation early in the course of the disease
should be a primary goal of management of TAO. The elucidation of the specific
cytokines that are released and active in the orbits of patients with TAO may aid
in the development of more specific immunomodulatory therapies. Improved
understanding of the pathophysiology of TAO may also help identify more
rational approaches to treatment. For example, identification of the molecules
involved in the inflammatory cascade which results in TAO may help predict
progression of disease and identify specific treatment modalities which may
benefit individual patients [11,70].

The pathogenesis of Graves' ophthalmopathy is becoming more clearly

understood. The volume of both the extraocular muscles and retroorbital
connective and adipose tissue is increased, due to inflammation and the
accumulation of hydrophilic glycosaminoglycans (GAG), principally hyaluronic
acid, in these tissues. GAG secretion by fibroblasts is increased by activated Tcell cytokines such as tumor necrosis factor (TNF) alpha and interferon gamma,
implying that T-cell activation is an important part of this immunopathology. The
accumulation of GAG causes a change in osmotic pressure, which in turn leads
to a fluid accumulation and an increase in pressure within the orbit. These
changes displace the eyeball forward and can also interfere with the function of
the extraocular muscles and the venous drainage of the orbits.

Fascia leher
Cervical Fascia adalah fascia yang ditemukan di daerah leher atau dalam bahasa
latin disebut Fascia Colli.
Fascia colli superficialis adalah lapisan di bawah kulit yang diisi oleh Platysma.
Di lapisan bawah musculus platysma terdapat lamina/fascia superficialis. Fascia
ini melingkari leher di luar muscullus sternomastoideus dan muscullus trapezius
sambil membungkus kedua otot itu.
Di posterior, fascia ini melekat pada ligamentum nuchea . Ke arah cranial ia
mencapai os.mandibula, procecus mastoideus, dan linea nuchae superior . Pada
celah antara angulus mandibulae dan procecus mastoideus. Fascia itu
membentuk dua lapisan yang membungkus glandula parotis, sebagian fascia ini
menebal membentuk ligamentum stylomandibulare.
Ke arah bawah, fascia superficialis melekat pada acromion, sisi atas os.clavicula
dan os.sternum. Di sebelah atas os sternum, fascia ini juga membentuk dua
lapisan, masing-masing melekat pada permukaan depan dan belakang incisura
jugularis sterni. Kedua lapisan ini membentuk spatium suprasternalis yang berisi
kelenjar getah bening serta cabang vena jugularis. Selain itu, fascia ini juga
membentuk carotid sheath yang membungkus arteri carotis comunis dan arteri
carotis interna, vena jugularis interna, dan nervus vagus serta cabang nervus
glossopharyngeus. Vena jugularis externa berada di lapisan luar fascia ini.
Di anterior, fascia ini membungkus otot-otot infrahyoid, yaitu musculus
sternohyoideus, musculus sternothyroideus, dan musculus thyroideus.
Di lapisan sebelah dalam fascia superficialis terdapat fascia pretrachealis,dan
fascia prevertebralis.

Fascia pretrachealis
Fascia pretrachealis melekat pada cartilage crioidea, tulang rawan larynx yang
berhubungan dengan trachea , melingkar dan membungkus trachea
,oesophagus,pharynx, glandula thyroidea ( dan glandula parathyroidea) di
bagian depan.
Di sebelah belakang atas fascia ini melekat pada tuberculum pharyngeum, ke
lateral melebar membentuk fascia buccopharingea dan berhubungan dengan

fascia musculus buccinatorius. Fascia pretrachealis mengikuti organ yang

dilapisinya, sedangkan otot yang terletak anterior terhadapnya di bagian bawah
leher memisahkan diri mencapai tempat perlekatannya masing-masing. Hal ini
menyebabkan adanya celah antara fascia pretrachealis dengan fascia yang
melapisi otot, disebut spatium pre-trachealis.

Fascia prevertebralis
Fascia prevertebralis terdapat di bagian depan corpus vertebra. Di antara
pharynx dan fascia prevertebralis ini terdapat celah sempit yang disebut spatium
retropharyngeum. Spatium retropharyngeum ini memanjang ke arah cranial
sampai musculus buccinatorius dan ke caudal sampai ke thorax hingga ke
diaphagma.
Spatium pretrachealis dan spatium retropharyngeum merupakan celah yang
memanjang dari leher sampai kedalam rongga thorax. Celah ini memungkinkan
penyebaran infeksi dari leher ke thorax.
Fascia prevertebralis membungkus vertebrae cervicalis beserta otot-otot yang
melekat padanya. Otot-otot ini termasuk musculi erector trunci dan musculi
prevertebrales, antara lain musculus scalenus anterior dan musculus scalenus
posterior . Dengan demikian, fascia ini sekaligus menutupi celah scalene
posterior dan terdorong oleh arteria axillaries beserta serabut saraf plexus
brachialis yang mencapai fossa axillaris melalui celah tersebut, membentuk
axillary sheath.