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    9 8 22 Ted PGR

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    alejandrashops12

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    9 8 22 Ted PGR

    Uploaded by

    alejandrashops12
    14 views14 pages

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    9 8 22 TED PGR

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    © © All Rights Reserved

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    14 views14 pages

    9 8 22 Ted PGR

    Uploaded by

    alejandrashops12

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
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    PRE-GRAND ROUNDS

    9/8/22

    Alejandra Maíz, MD
    PGY-3

    James Zhao, MD
    Oculoplastics Fellow
    • I have no financial disclosures
    • Consent for photography and recording was obtained
    and can be found scanned into the patient chart
    38y M presented with complaint of “bulging” eyes and double vision
    that gradually started over 2 months.
    Differential Diagnosis
    INFECTION NEOPLASM VASCULAR LESION
    Fungal Lymphoma Capillary hemangioma
    Bacterial Cavernous venous
    Metastatic disease
    malformation
    Rhabdomyosarcoma Lymphangioma
    Optic pathway glioma Orbital venous varices
    INFLAMMATION Optic nerve sheath meningioma Arteriovenous malformations
    Sarcoidosis Schwannoma Cavernous sinus malformations
    Carotid-cavernous fistula
    IgG4 Disease Neurofibroma
    Granulomatosis with
    polyangiitis
    NSOI
    TED
    What history questions would
    you like to ask?
    What exam would you like to do?
    Exam Findings
    Test/Anatomy Right Eye (OD) Left Eye (OS)
    Visual Acuity 20/25-3 20/20-1
    Pupils 5 -> 3 (no rAPD) 5 -> 3 (no rAPD)
    Intraocular Pressure (iCare) 17 16
    Hertel 23.5-24 21
    Extraocular Movements 0% supraduction, 100% 70% supraduction, 100%
    aDd/aBd/infra-duction aDd/aBd/infra-duction
    Alignment 20-25 PD LHT
    Lids/Lashes 3 mm superior scleral 4 mm superior scleral show,
    show, temporal flare, lid temporal flare, lid lag, 1 UL
    lag, 1+ UL edema edema
    Conjunctiva/Sclera Tr-1+ conj injection, tr Tr-1+ conj injection, tr
    caruncle edema caruncle edema
    Cornea tr inf PEE 2+ PEE inferior 30%
    Anterior Chamber Deep and quiet Deep and quiet
    Iris Round and reactive Round and reactive
    Lens Clear Clear
    Disc, c:d Sharp margins, 0.3 Sharp margins, 0.3
    What work-up/testing would you
    like to obtain?
    Diagnosis/Management

    How would you treat this patient?


    Prognosis

    How would you counsel this patient?


    Key Points
    • TED = activation of orbital fibroblasts by
    autoantibodies directed against thyroid receptors
    → expression of inflammatory cytokines, GAG
    synthesis, adipocyte differentiation (→ expansion
    of orbital fat)
    • Hyperthyroid, hypothyroid, or in absence of thyroid
    dysfunction
    • Muscles involved: IR → MR → SR → LR (most →
    least frequently involved)
    • Clinical diagnosis (CAS)
    • Rundle’s Curve (1 year in non-smokers, 2-3 years in
    smokers)
    – Reactivation 5-10% patients over their lifetime
    • Management
    – Establish euthyroid state (thyroid levels upper half of
    normal range)
    – Eliminate smoking/smoke exposure
    – Treat dry eye
    – Fresnel prisms
    – IV steroids
    – Tepezza (ab against IGF-1 receptor)
    – Order of surgeries: decompression → strabismus →
    lids

    https://eyewiki.aao.org/File:CAS.jpg
    https://webeye.ophth.uiowa.edu/eyeforum/tutorials/thyroid-eye-disease/4a-TED-treatment.htm

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