Bệnh nhãn giáp là biểu hiện ở mắt của các bệnh liên quan tuyến giáp. Bệnh lý này có nhiều tên gọi khác nhau như bệnh Graves, bệnh nhãn giáp, bệnh lý hốc mắt của Graves hay bệnh mắt liên quan tuyến giáp.
Thyroid Eye Disease Kenn Freedman MD PhD TTUHSC Department of Ophthalmology and Visual Sciences Thyroid Related Eye Disease Many Different Names Thyroid Related Orbitopathy (TRO) Thyroid Associated Orbitopathy (TAO) Thyroid Eye Disease (TED) Graves Ophthalmopathy (GO) Thyroid Related Immune Orbitopathy (TRIO) Summary TED usually a clinical diagnosis – but useful testing can include TSI level, CT of orbits TED can occur in patients that are hypo- , hyper or Euthyroid TED effects Orbital Tissues – with implications for optic nerve, extraocular muscles and Eyelids Corticosteroid treatment – can be useful at times in these patients, especially if they have compressive optic neuropathy Normal Eyelids and Orbit LPS Levator Normal Eyelid Positions From Eyeimaginations Upper- 1-2 mm below upper limbus LPS – Levator Palpebrae Superioris Lower - at lower limbus Optic Nerve Some Terminology Eyelid Retraction – eyelid open more than normal Proptosis - Forward displacement of globe (eyeball) Lagophthalmos – inability to close eyelids all the way Lid Lag – Inability for upper eyelid to follow globe downward Chemosis – edema of the conjunctiva Strabismus – misalignment of the ocular axes Optic Neuropathy – Damage to the optic nerve (e.g compression) Corneal Exposure – drying out of cornea with associated problems and risks TED- Associations Graves Disease – one most common autoimmune conditions in US Hashimoto Thyroiditis Primary Hyperthyroidism Thyroid Cancer Signs/Symptoms of Hyperthyroidism Palpitations Tremor Nervousness Weight Loss Increased appetite Heat intolerance Sweating Fatigue Irritability Increased metabolic rate Orbital Disease and Thyroid Status TRO diagnosed before hyperthyroid - 22% simultaneous hyperthyroid - 20% following hyperthyroidism - 57% *Some never hyperthyroid *May occur with Hashimoto’s thyroiditis and hypothyroidism TED can be seen at any level of thyroid status Diagnosis Thyroid Function Tests Free T4 , T3 Resin Uptake, TSH (thyrotropin) TSI – Thyroid Stimulating Immunoglobulin (Ab) IgG Antibodies that bind to thyrotropin (TSH) receptors on thyroid gland (also called Thyrotropin Receptor Abs) * use in diagnosis when patient Euthyroid * can be a measure of active inflammatory phase Other Antibody Tests Thyroid Peroxidase antibody TPO Ab Hashimoto’s or Graves Disease (Autoimmune Thyroiditis) Thyroglobulin antibody Tg Ab Hashimoto’s or Thyroid Cancer Use of Rituximab 1000mg – Systemically – cycles separated by weeks shown to deplete peripheral CD20+ cells- with significant improvement of active Graves Orbitopathy Initial Study – 12 patients with TED treated with Rituximab showed clinical improvement Ophthal Plast Reconstr Surg 2010 Sep-Oct;26(5):310-4 doi: 10.1097/IOP.0b013e3181c4dfde Rituximab for thyroid eye disease Silkiss RZ1, Reier A, Coleman M, Lauer SA Treatment Compressive Optic Neuropathy Possible Signs: Decreased Visual Acuity Loss of Color Vision RAPD VF loss Disc edema (50% or less) CT – signs of compression in orbital apex VF loss from optic nerve compression Treatment of Compressive Optic Neuropathy Systemic High Dose Steroids If fail, or recurrence on tapering consider Orbital radiation* Orbital Decompression External approach Trans-nasal endoscopic approach Orbital Decompression Indications Compressive Optic Neuropathy Severe Proptosis resulting in Exposure problems Globe Luxation Severe Disfigurement Summary of Treatment of Active Inflammatory Disease From JNO 2014; 34:186 Surgical Planning - order Tarsorrhaphy Orbital decompression Muscle Procedures Lid Retraction Surgery Can confuse hypotropia with UL retraction or Hypotropia can accentuate appearance of UL retraction One reason to eye muscle surgery before eyelid surgery Muscle (EOM) Procedures Wait for stability of measurements and resolution of inflammatory component Want also stability of Thyroid Hormone status GOAL: release of restriction Esotropia – Unilateral or Bilateral MR Recession(s) Hypotropia – Unilateral IR recession Surgical numbers in tables of limited value Adjustable suture - under anesthesia IR recession 2.5-3 PD/mm Upper Lid Retraction Levator Recession a Anterior approach b Posterior approach * add small Tarsorrhaphy (lateral canthoplasty) for the lateral scleral show Subconjunctival Botulinum Toxin A (OPH 2002; 109:1183, and OPRS 2004; 20:181-185) Botulinum Toxin for UL Retraction Can be used in inflammatory phase of TED as temporizing measure for UL retraction until stability for surgery is reached 10, , or 2.5 U injected transconjunctivally just above superior tarsal border in the elevator complex Levator Recession Lower Lid Retraction Lower Lid Retractor Lengthening Procedure Uses scleral or cartilage or artificial spacer e.g eyeplastics.com/eyelid –lid-retraction-thyroid-eye-disease Recent Case 32 yo woman Previously healthy Dx with Bell’s Palsy? MRI scan negative except for EOM’s Lab: T4, TSH normal + TSI + TPO Either Grave’s or Hashimoto’s? Summary TED usually a clinical diagnosis – but useful testing can include TSI level, CT of orbits TED can occur in patients that are hypo- , hyper or Euthyroid TED effects Orbital Tissues – with implications for optic nerve, extraocular muscles and Eyelids Corticosteroid treatment – is useful at times in these patients, especially if they have compressive optic neuropathy O LORD, our Lord, how majestic is your name in all the earth! Psalm 8:1 Banff NP , Alberta Canada ...Thyroid Related Eye Disease Many Different Names Thyroid Related Orbitopathy (TRO) Thyroid Associated Orbitopathy (TAO) Thyroid Eye Disease (TED) Graves Ophthalmopathy (GO) Thyroid Related Immune... muscles and Eyelids Corticosteroid treatment – can be useful at times in these patients, especially if they have compressive optic neuropathy Normal Eyelids and Orbit LPS Levator Normal Eyelid Positions... Positions From Eyeimaginations Upper- 1-2 mm below upper limbus LPS – Levator Palpebrae Superioris Lower - at lower limbus Optic Nerve Some Terminology Eyelid Retraction – eyelid open