12/11/2008

GravesOphthalmopathy (GO)
Clinicalpresentation
&
Medicaltreatment
Parima Hirunwiwatkul,MD
DepartmentofOphthalmology,Facultyof
Medicine,Chulalongkorn University

EyeinvolvementinGO
Class0

Nosymptomsorsigns

ClassI

Onlysigns,nosymptoms(lidretraction,stare,lidlag)

ClassII

Softtissueinvolvement

ClassIII

Proptosis

ClassIV

Extraocular muscleinvolvement

ClassV

Cornealinvolvement

ClassVI

Sightloss(opticnerveinvolvement)

Clinicalpresentation
Drynessandirritation
Inflammationandpain
Visualdisturbance
Afferent:Decreaseacuity,dimming,scotoma,
colorchange
Efferent:doublevision

Cosmetic

TreatmentofTRO
Avoidriskfactors
Symptomatictreatment
Lubricant
Anti
Antiinflammation
inflammation:steroids
: steroids

Medicaltreatment

Lubricants

Systemicsteroids
Immunosuppressive
Botulinum toxin

Surgicaltreatment

Nosymptomsorsigns

Artificialtears:
Preservativeartificialtear
Disappearedpreservative
Nonpreservative/preservativefree
Non preservative/ preservative free

Form:
Eyedrop:bottle,tube
Eyegel

Symptoms:

None

Signs:

None

Treatment:

None

12/11/2008

Onlysigns,nosymptoms
Symptoms:
Signs:
Treatment:

unequaleye

Lidretraction,stare,lidlag
Controlthyroidhormonecondition
Botulinum toxininjectedtoMuller
muscle

Proptosis
Symptoms:
Signs:
Treatment:

Extrudedeyeballfromglobe
Dryness
Proptosis
Lagophthalmos
Cornealexposure
Avoidrisk,sleepposition
Lubricants
Tarsorrhaphy :medical/surgical

Softtissueinvolvement
Symptoms:

Deepconjunctival injection,especially
over the rectus muscle insertions
overtherectusmuscleinsertions.
Conjunctival chemosis
Edemaofthecaruncle
Inflammationmayresultinperiorbital
edemaanderythema.

Signs:

Treatment:

Dryness,pain,redness
Decreasedvision

Signs:
Signs:

Conjuntival injection
Cornealulceration/perforation

Treatment:

Lubricants,topicalantibiotics
Tarsorrhaphy :medical/surgical
Cornealsurfacereconstruction:AMT,
cornealtransplantation

Avoidrisk,sleepposition
Lubricants
Topicalsteroids(+ oral)

Extraocularmuscleinvolvement
Symptoms:

Signs:

Treatment:

Doublevision
Cannotmovetheeyes
Misalignment
Misalignmentofglobe
of globe
LimitationofeyemovementbyEOM
involvement
Symptomatic:Patching,prism,Botulinum
toxininjectedtoRectusmuscle
Systemicsteroids

Cornealinvolvement
Symptoms:

Pain,irritation,redness,
cosmetic

Sightloss
Symptoms:
Si
Signs:
Treatment:

Decreasedvision
opticnervefunction:color,
g
,
,
brightness,contrast,VF
RAPDpositive
+ Discswelling/atrophy
Medical/surgicaldecompression:
systemic/localsteroidsinjection,
Botulinum toxininjection,OR,
surgery

12/11/2008

Recommendations

*ThispaperisalsobeingpublishedintheMarch2008issueofthejournal,
EuropeanJournalofEndocrinology,vol.158,no.3.

Referralto
combinedthyroid
eyeclinicsand
initialassessment

SmokingandGO

Managementof
hyperthyroidism
inpatientswith
GO

Othersimple
measuresthat
mayalleviate
symptoms

Gradingseverity
andactivityofGO

Management of
Managementof
sightthreatening
GO

Managementof
moderateto
severeGO

Managementof
mildGO

Specialsituations

Referraltocombinedthyroideyeclinics
andinitialassessment
ManagementissuesofGOthat
shouldbeaddressedby
both nonspecialists andspecialists
bothnonspecialists
and specialists

ShouldallpatientswithGObereferredto
combinedthyroideyeclinics?

Primarycarephysicians,generalpractitioners,
generalinternistsandspecialists,whohaveno
particularexpertiseinmanagingGO,should
referpatientswithGO,exceptforthemildest
cases,tocombinedthyroideyeclinicsfor
furtherassessmentandmanagement

Referurgently
Symptoms
Unexplaineddeteriorationinvision
Awarenessofchangeinintensityorqualityofcolour
visioninoneorbotheyes
Historyofeye(s)suddenlypoppingout
Hi
f
( ) dd l
i

(Globesubluxation)

Referurgently
Compressiveopticneuropathy(Dysthyroid
opticneuropathy)
Exposurekeratopathycornealmelting
cornealperforation
corneal perforation

Signs
Obviouscornealopacity
Corneastillvisiblewhentheeyelidsareclosed
Discswelling

12/11/2008

Refernonurgently

SmokingandGO

Symptoms
Eyesabnormallysensitivetolight:troublesomeordeterioratingover
thepast12months
Eyesexcessivelygrittyandnotimprovingafter1weekoftopical
lubricants
Paininorbehindtheeyes:troublesomeordeterioratingoverthepast
12months
Progressivechangeinappearanceoftheeyesand/oreyelidsoverthe
Progressive change in appearance of the eyes and/or eyelids over the
past12months
Appearanceoftheeyeshaschangedcausingconcerntothepatient
Seeingtwoseparateimageswhenthereshouldonlybeone

Signs

Troublesomeeyelidretraction
Abnormalswellingorrednessofeyelid(s)orconjunctiva
Restrictionofeyemovementsormanifeststrabismus
Tiltingoftheheadtoavoiddoublevision

Issmokingrelatedtotheoccurrence,
severity,andprogressionofGO?
AllpatientswithGravesdiseaseshouldbeinformedoftherisksof
smokingforGOemphasizingthedetrimentaleffectsofsmokingon:
developmentofGO(IIb,B)
deteriorationofpreexistingGO(IIb,B)
effectivenessoftreatmentsforGO(IIb,B)
progressionofGOafterradioiodinetreatment(Ib,A)
Ifadvicealoneisineffective,referraltosmokingcessationclinics,orother
smokingcessationstrategiesshouldbeconsidered(IV,C)

Managementofhyperthyroidismin
patientswithGO

Managementofhyperthyroidismin
patientswithGO

1.Iscorrectionofthyroiddysfunction
importantforGO?

2.Istherearelationshipbetweenmodalityof
treatmentforhyperthyroidismandthecourseofGO?

Euthyroidism shouldberestoredpromptlyandmaintained
stablyinallpatientswithGO(III,B)

PatientswithactiveGOgivenradioiodineshouldbeofferedprophylactic
steroidcover(commencingwith0.30.5mgofprednisone/kg/dayorally13
daysafterradioiodineandtaperingthedoseuntilwithdrawalabout3
monthslater)(Ib,A)

Frequentmonitoringofthyroidstatus(every46weeks)is
imperativeintheinitialphasesoftreatmentwhenchangesin
thyroidstatusareexpected(IV,C)

Shorterperiodsofglucocorticoid therapy(12months)maybeequally
protective(IV,C)
PatientswithinactiveGOcansafelyreceiveradioiodinewithoutsteroid
cover,aslongashypothyroidismisavoided(IIb,B),particularlyifotherrisk
factorsforGOprogression,suchassmoking,areabsent(IV,C)

Othersimplemeasures
thatmayalleviatesymptoms
Arethereworthwhilesimplemeasuresthatcan
relievesomeofthesymptomsofGO?

Lubricanteyedropsduringthedayand/orlubricantointmentsat
nighttimearerecommendedforallpatientswithGOwhohave
symptomsofcornealexposure(III,B)

ManagementissuesofGOthat
shouldbeaddressed
in specialists centers
inspecialistscenters

Patientswithsymptomaticdiplopia shouldbegivenprismsif
appropriate(IV,C).
Botulinum toxininjectionmaybeconsideredforupperlid
retractionincentres whohaveexperienceandexpertiseinthis
technique(IV,C).

12/11/2008

Severitymeasures

GradingseverityandactivityofGO
Activitymeasuresbasedonfeaturesofinflammation:
clinicalactivityscore(CAS)
Spontaneousretrobulbar pain
Pain on attempted up ordowngaze
Painonattemptedup
or down gaze
Rednessoftheeyelids

Lidaperture
distancebetweenthelidmarginsinmmwiththepatientlookingintheprimaryposition,
sittingrelaxedandwithdistantfixation

Swellingoftheeyelids
Rednessoftheeyelids
Rednessoftheconjunctiva
Conjunctival oedema
Inflammationofthecaruncle orplica
p
Exophthalmos
usingthesameHertel exophthalmometer

Rednessoftheconjunctiva

Subjectivediplopia score

Swellingoftheeyelids

Eyemuscleinvolvement

Inflammationofthecaruncle and/orplica
Conjunctival oedema
ACAS (sumofallitemspresent) >3/7indicatesactiveGO

GradingseverityandactivityofGO
SeverityclassificationsinGO

0=nodiplopia;1=intermittent,2=inconstant,3=constant
ductions indegrees

Cornealinvolvement(absent/punctate keratopathy/ulcer)
Opticnerveinvolvement
bestcorrectedvisualacuity,colorvision,opticdisc,RAPD(absent/present),plusvisualfieldsif
opticnervecompressionissuspected

GradingseverityandactivityofGO
SeverityclassificationsinGO
2.ModeratetosevereGO:
NosightthreateningGO

1.SightthreateningGO:
patientswithdysthyroid opticneuropathy(DON)
and/orcornealbreakdown.
Thiscategorywarrantsimmediateintervention.

GradingseverityandactivityofGO
SeverityclassificationsinGO

Usuallyhaveanyoneormoreofthefollowing:
lidretraction> 2mm,moderateorseveresofttissue
involvement,exophthalmos > 3mmabovenormalforraceand
gender,inconstantorconstantdiplopia.

Eyediseasehassufficientimpactondailylifetojustify
therisksofimmunosuppression (ifactive)orsurgical
intervention(ifinactive).

ManagementofmildGO
Areglucocorticoids and=ororbital
radiotherapyindicatedorusefulinmildGO?

3.MildGO:
Onlyaminorimpactondailylifeinsufficientto
justifyimmunosuppressiveorsurgicaltreatment.
Theyusuallyonlyhaveoneormoreofthe
following:*minorlidretraction(<2mm),$mildsofttissue
involvement,%exophthalmos <3mmabovenormalforrace
andgender,transientornodiplopia,,cornealexposure
responsivetolubricants

Glucocorticoids arerarelyjustifiedinmildGO
astherisksoutweighthebenefits(IV,C).

12/11/2008

ManagementofmildGO

ManagementofmildGO

Isawaitandseestrategyreasonable?

andexophthalmos bemanagedandwheninthecourseof

Howshouldmildeyelidretraction,softtissueswelling,
theorbitaldisease?

Watchfulwaitingisappropriateforthe
majorityofpatientswithmildGO(IV,C).

Inaminorityofpatientswithmilddisease,qualityoflife
maybesoprofoundlyaffectedastojustifyusing
treatmentsasformoderatetoseveredisease(IV,C).

Takehomemessage
Earlydetectionandreferralto
ophthalmologist