III- C1-8 MATEMATICO  MATIAS  MAULION MEDENILLA  MEDINA, K.  MEDINA, S.

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

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.

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

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

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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.