Case Study 15 - CC: Eye irritation and dryness

Patient History
HPI:
The patient is a 43 year-old female insurance sale agent who presents for her annual eye exam. She admits to symptoms of ocular irritation and burning when she wakes up in the morning. The eyes also feel dry in the afternoon and look red. She has also noted that her eyelids are of different height; noticed it when putting make-up on. She denies significant problems with driving, TV watching, computer use or reading. She also denies flashes, floaters or diplopia.

Past Ocular History:
Myopia. No prior eye surgeries, hx of eye trauma, amblyopia or strabismus.

Ocular Medications:
None

Past Medical History:
None

Surgical History:
None

Past Family Ocular History:
Negative for macular degeneration, glaucoma or blindness

Social History:
Non-smoker

Medications:
None

Allergies:
None

ROS:
Patient admits to mild anxiety and to unexplained palpitations. Has not seen a doctor for this. Otherwise she denies any recent illness or any new CNS, heart, lungs, GI, skin or joint symptoms.

Ocular Exam

Visual Acuity (cc):
OD: 20/20
OS: 20/20

IOP (tonoapplantation):
OD: 18 mmHg
OS: 16 mmHg

Pupils:
Equal, round and reactive to light, no APD OU

Extraocular Movements:
Limited downward gaze OU with eyelid elevation (eyelid lag). No other restrictions. No nystagmus OU.

Confrontational Visual Fields:
Full to finger counting OU

External:
Mild upper eyelid fullness OU

Slit Lamp:

Dilated Fundus Examination:

Other:
Hertel exophthalmometry: 23mm OD, 22mm OS at 108

Diagnosis
Grave’s ophthalmopathy

Discussion

Differential Diagnosis:
This patient presents with possible Grave's ophthalmopathy, also know as thyroid ophthalmopathy. Other diseases in the differential diagnoses include conditions that cause orbital congestion (orbital tumors, orbital infections like orbital cellulitis), other causes of orbital inflammation (orbital pseudotumor - now called idiopathic orbital inflammation, Granulomatosis with polyangiitis, orbital myositis).

Definition:
Grave's ophthalmopathy occurs secondary to an autoimmune process which leads to changes in orbital content (mainly extraocular muscles and orbital fat). The process is thought to be an antibody-mediated reaction against the thyroid stimulating hormone (TSH) receptor, although specific immunoglobulins are found in only 50% of patients via blood tests. T-cell lymphocytes also migrate to the orbit where they are stimulated to initiate an immune response. This causes infiltration and enlargement of the extraocular muscles (with sparing of the muscle tendons), and orbital congestion (which accounts for most of the clinical findings in Grave's ophthalmopathy). Patients with thyroid ophthalmopathy do not always have active thyroid disease.

Examination:
Symptoms may include upper and lower eyelid retraction, dry eyes, double vision, restriction of extraocular movements, excessive tearing, and eye irritation. Exam findings may show exophthalmos or proptosis (forward movement of the globe), lagophthalmos (inability to close eyes), strabismus (misalignment of eyes), swelling of the eyelids, corneal dryness, chemosis of the conjunctiva, increased intraocular pressure, and, in extreme cases, congestion of the optic nerve by the swollen orbital structures and vision loss.

Work up of Grave’s ophthalmopathy includes a non-contrast orbital CT which will often show bilateral extraocular muscle (EOM) enlargement with sparing of tendons. Other work-up can include TSH, and free T3, T4 levels.

Treatment:
Treatment of Grave’s ophthalmopathy is independent of systemic disease. Treatment depends on signs and symptoms and severity of disease. Artificial tears can be used for corneal exposure. Eyelid surgery can be considered for severe lid retraction. High dose glucocorticoids are used for severe orbital congestion and optic neuropathy. Steroid-sparring agents and additional immunomodulators are also used (cyclosporine, azathioprine). Sometimes, surgical decompression of the orbit is needed to prevent severe exophthalmos and optic nerve compression. If patients develop diplopia secondary to muscle enlargement and fibrosis, prisms and then strabismus surgery are offered after the inflammatory response is controlled. Eyelid surgery is offered in patients that have severe exposure due to a fibrotic levator muscle. Most cases of grave’s ophthalmopathy stabilize within 8-36 months.

1. Which is not a common sign of thyroid ophthalmopathy or Grave’s ophthalmopathy?
   • Double vision
   • Dry eyes and irritation
   • Eyelid retraction
   • Enophthalmos
   • Conjunctival injection (redness)
2. True or False: Patients with thyroid ophthalmopathy will also have active thyroid disease.
3. Which clinical finding is not typical with thyroid ophthalmopathy?
   • Strabismus
   • Corneal dryness
   • Proptosis
   • Ptosis
   • Lagophthalmos

References/Resources

1. Which is not a common sign of thyroid ophthalmopathy or Grave’s ophthalmopathy?
d. Enophthalmos
This is not a sign of typical thyroid orbitopathy.

2. True or False: Patients with thyroid ophthalmopathy will also have active thyroid disease.
FALSE
Patient can present with thyroid orbitopathy and be euthyroid or hypothyroid on laboratory testing.

3. Which clinical finding is not typical with thyroid ophthalmopathy?
Strabismus
d. Ptosis
Most patients would not present with ptosis but the reverse, lid retraction.