Download CASE 8

III- C1-8
MATEMATICO  MATIAS  MAULION
MEDENILLA  MEDINA, K.  MEDINA, S.
CASE 8
SALIENT FEATURES
 75 year-old, Male
 CC: Blurring of Vision
 Visual Acuity: 20/50 OD 20/400 OS
 Bilateral Hyperemic Conjunctiva
 (+) Afferent Pupillary Defect OS
 Minimal Lens Opacity
 Palpitations
 Tearing
WHAT IS YOUR PROBABLE
DIAGNOSIS IN THIS CASE?
WHAT OTHER DIAGNOSTIC
TEST WOULD YOU DO?
Diagnostic Tools
 Serum TSH
 Serum Free T4 & T3
 Tests for antibodies
 Anti-thyroglobulin
 Anti-microsomal
 Anti-thyrotropin receptor
 Orbital Imaging
 Ultrasound
 CT Scan
Serum TSH, Free T4 & T3
 For screening for thyroid disease
 Highly sensitive and specific
 Serum TSH
 useful to establish a diagnosis of
hyperthyroidism or hypothyroidism
Blood Assays
 TRAb (thyroid receptor antibody), TBII (TSH-
binding inhibitor immunoglobulin), and LATS
(long-acting thyroid stimulator) assays
 Measure the binding of TSH to a solubilized
receptor
 TSI (thyroid-stimulating immunoglobulin)
assays
 Measure the ability of immunoglobulin G (IgG) to
bind to the TSH receptor on cells and to stimulate
adenylate cyclase production
Blood Assays
 Antithyroid antibody test
 antithyroglobulin test
 Thyroid peroxidase test
 also called the antimicrosomal antibody test
and the antithyroid microsomal antibody test.
 Thyroid peroxidase antibodies and
antibodies to thyroglobulin
 Useful when trying to associate eye findings
with a thyroid abnormality, such as euthyroid
Graves disease.
Orbital Imaging
 Ultrasound
 Quick confirmation of thickened muscles or an
enlarged superior ophthalmic vein.
 CT scan and MRI
 Reveals thick muscles with tendon sparing and
dilated superior ophthalmic vein
 Apical crowding of the optic nerve
 MRI is more sensitive for showing optic nerve
compression.
 CT scan is performed prior to bony decompression
because it shows better bony architecture.
EXPLAIN THE CAUSE OF
RAPD IN THE LEFT EYE.
Relative Afferent Pupillary
Defect
 one of the most important assessments to make
in a patient complaining of decreased vision is
whether it is due to an ocular problem or to a
potentially more serious optic nerve problem
 usually a sign of optic nerve disease
 may also occur in retinal disease
 not occur in media opacities (corneal disease,
cataract, and vitreous hemorrhage)
Swinging Flashlight Test
 a light is alternately shone into the left and right
eyes
 NORMAL response
 equal constriction of both pupils, regardless
of which eye the light is directed at
 intact direct and consensual pupillary light
reflex
Swinging Flashlight Test
 AFFERENT PUPILLARY DEFECT
 light shone in the affected eye will produce less
pupillary constriction than light shone in the
unaffected eye
 light directed in the affected eye will cause only
mild constriction of both pupils
 decreased response to light from the afferent defect
 light in the unaffected eye will cause a normal
constriction of both pupils
 intact afferent path and an intact consensual pupillary
reflex
Afferent Pupillary Defect
 Optic Nerve Lesion
 the pupillary light response (the direct response in
the stimulated eye and the consensual response
in the fellow eye) is less intense when the involved
eye is stimulated than when the normal eye is
stimulated
Orbital disease
• compressive damage to the optic
nerve from thyroid related orbitopathy
• compression from enlarged EOM in
the orbit
Other Optic Nerve Disorders
 Optic neuritis
 Ischemic optic neuropathies
 arteritic (Giant Cell Arteritis) and non-arteritic causes
 loss of vision or a horizontal cut in the visual field
 Glaucoma
 if one optic nerve has particularly severe damage
 Traumatic optic neuropathy
 direct ocular trauma, orbital trauma, and even more
remote head injuries which can damage the optic
nerve as it passes through the optic canal into the
cranial vault
Other Optic Nerve Disorders
 Optic nerve tumor
 primary tumors of the optic nerve (glioma,
meningioma)
 tumors compressing the optic nerve (sphenoid
wing meningioma, pituitary lesions)
 Radiation optic nerve damage
 Optic nerve infections or inflammations
 Cryptococcus, Sarcoidosis, Lyme disease
 Surgical damage to the optic nerve
WHAT IS YOUR TREATMENT
PLAN?
GOALS
 Regulation of Thyroid Hormones
 Avoid Corneal Damage
 Reduce Inflammation
 Orbit Decompression
Regulation of Hormones
 Refer the patient to Endocrinologist
 Anti-Thyroid Hormones
 PTU, Methimazole, Carbimazole
Avoid Corneal Damage
 Topical lubrication of the ocular surface
 Tarsorrhaphy
 Alternative option when the complications of
ocular exposure can't be avoided solely with
the drops
Reduce Inflammation
 Corticosteroids
 Efficient in reducing orbital inflammation
 Benefits cease after discontinuation
 Limited because of many side effects
 Radiotherapy
 Alternative option to reduce acute orbital
inflammation
 Controversial due to its efficacy
Reduce Inflammation
 Smoking cessation
 A simple way of reducing inflammation
as pro-inflammatory substances are
found in cigarettes.
Orbit Decompression
 Surgery
 To improve the proptosis and address
the strabismus causing diplopia
 Stable patient for at least 6 months
 Urgent: To prevent blindness from optic
nerve compression
Orbit Decompression
 Eyelid Surgery
 Most common surgery performed on
patients with Grave’s Ophthalmopathy
 Lid lengthening Surgery
 Done on upper and lower eyelid
 To correct the patient’s appearance and
ocular surface symptoms
Orbit Decompression
 Marginal Myotomy
 Levator Palpabrae muscle
 Reduce palpebral fissure height by 2-3 mm
 Lateral Tarsal Canthoplasty
 Performed with Marginal Myotomy of
Levator Palpebrae
 In a more severe upper lid retraction or
exposure keratitis
 Lower the upper eyelid by as much as 8 mm
Orbit Decompression
 Mullerectomy
 Resection of Muller muscle
 Eyelid Spacer Grafts
 Recession of Lower Eyelid Retractors
 Blepharoplasty
 To debulk the excess fat in the lower
eyelid
THANK YOU!
TO MICH!
 NING, UNG TREATMENT PO
AFTER THIS SLIDE IS FROM
GELYN
 UNG TREATMENT BEFORE THIS
SLIDE IS FROM ME… KAW NA
BAHALA MAGMIX… MEJO SAME
SAME LANG NAMAN…
Treatment
 Short term goal:
 To conserve useful vision
 Long term goal:
 To restore the orbital anatomy
 Glucocorticoids
 Rationale: Immunosuppressive and anti-inflammatory
 Decrease the production of mucopolysaccharides by
the fibroblasts
 methylprednisolone 1 g every other day for 3
cycles
 SE: immunosuppression, hyperglycemia,
osteoporosis, necrosis, weight gain, Cushing
syndrome
 Orbital radiation
 Rationale: Anti-inflammatory; radiosensitivity of
activated orbital T cells and fibroblasts
 Cumulative dose of radiation: 20 Gy per eye,
fractionated over a 2-week period
 SE: radiation retinopathy, cataract
 Orbital decompression
 at least 2 orbital walls usually are decompressed
(traditionally, the medial wall and floor of the
orbit).
 Medial decompression for compressive
neuropathy must be taken posteriorly all the way
to the apex of the optic canal.
 Surgery can be approached from a transorbital or
trans-sinus route.
 Strabismus surgery
 Inferior rectus muscle recession may decrease
upper lid retraction, but it often results in lower lid
retraction despite dissection of the lower lid
retractors.
 Because the inferior rectus muscle has subsidiary
actions (excyclotorsion and adduction), inferior
rectus muscle recessions may lead to a
component of intorsion and A-pattern strabismus.
 Lid-lengthening surgery
 2-3mm of upper lid retraction can be ameliorated
with a Müller muscle excision.
 Lateral levator tenotomy is often helpful to
decrease the temporal flare.
 If further amounts of lid recession are required,
levator recession can be considered.
 Lower lid-lengthening usually requires a spacer
material.
 Blepharoplasty
 Lower lid blepharoplasty can be approached
transconjunctivally if no excess lower lid skin is
present
 Upper lid blepharoplasty is performed
transcutaneously with conservative skin excision.
 Brow fat resection may be considered.
 Dacryopexy may be required if lacrimal gland
prolapse occurs.