Good Hope, Heartlands, and Solihull Eye Clinics

hyroid Associated Orbitopathy
(TAO)/ Thyroid Eye Disease..notes for profesionals

David Kinshuck

TAO assessment

History

Examination

Purpose of assessment
The aim is to determine activity and urgency of treatment.
The aim is to determine activity and urgency of treatment.

inactive
function eg diplopia or congested orbit  cosmetic

Vision etc

Soft tissue

Slit-lamp

  • cornea...epitheliopathy
  • precorneal tear film, ulcer, scar
  • IOP
  • IOP up gaze

dilate

  • optic disc swelling/atrophy
  • choroidal folds

EOM

  • squint

Orthoptics

  • HESS, BSV

Investigate

 

Proptosis

  • exophthalmos
  • record with same instrument, and record name of instrument
  • record and use the same intercanthal distance...in primary position
  • retropulsion..present...vision is normal, reduced, vision reduces (that is can press the eyes back in socket)

Summary

 

Hydraulic disease

Occasionally there may be no response to steroids...the actual disease is inactive

Interpretation of blood tests etc

Subclinical  hypothyroidism

Other factors linked to TAO

environmental

  • stress
  • smoking
  • drugs (eg amiodarone)
  • infection
  • low iodine in diet

modulating factors

  • pregnancy
  • E2 contraception

genes

  • eg DR3 CTAL4

 

Treatment of thyroid condition itself

Treatment of TAO

Steroid use in TAO
active TAO, and if condition severe enough to treat
IV methylprednisolone in the acute stage if condition is severe enough to treat:
1g day for 3 days each week for 2 weeks
improved poor response
oral steroids short term decompression surgery

 

Severity of TAO...is treatment needed?

Patients with severe disease will have many signs and many of these (eg exophthalmos, diplopia, optic atrophy) will remain even after the disease becomes inactive.

Patients will mild disease will have few if any residual signs when the condition settles.

Patients with moderate disease will have some signs after the active phase finishes.

The active period generally does not last longer than 2 years.

 

IV methylprednisolone in the active phase

Doctors need to determine which patient is in which group, when the disease is active, and if the activity is enough to lead to significant problems when the activity settles.

Treatment is given in the active phase (red block opposite) in all of the severe cases, and most of the moderate cases, and few of the mild cases.

Treatment (IV methylprednisolone) is given as early as possible in the active phase, and repeated if the activity does not settle. Severe cases may still need surgical decompression in addition, even in the active phase.

Patients with mild disease may prefer no treatment...as the steroids themselves have side effects. But those with severe disease should nearly always be offered treatment, as well as stopping smoking and having their thyroid disease itself stabilised.

 

After the active phase

After the active phase, residual ('hydraulic') signs can only be treated with surgery.

 

Source, links etc