GravesOphthalmopathy

(GO)
Clinicalpresentation
&
Medicaltreatment
ParimaHirunwiwatkul,MD
DepartmentofOphthalmology,Facultyof
Medicine,ChulalongkornUniversity

Clinicalpresentation
Drynessandirritation
Inflammationandpain
Visualdisturbance
Afferent:Decreaseacuity,dimming,scotoma,
colorchange
Efferent:doublevision

Cosmetic

EyeinvolvementinGO

TreatmentofTRO
Avoidriskfactors
Symptomatictreatment
Lubricant
Antiinflammation:steroids

Medicaltreatment
Systemicsteroids
Immunosuppressive
Botulinum toxin

Surgicaltreatment

Lubricants
Artificialtears:
Preservativeartificialtear
Disappearedpreservative
Nonpreservative/preservativefree

Form:
Eyedrop:bottle,tube
Eyegel

Nosymptomsorsigns

Onlysigns,nosymptoms

Softtissueinvolvement

Proptosis

Extraocular muscleinvolvement

Cornealinvolvement

Sightloss

*ThispaperisalsobeingpublishedintheMarch2008issueofthejournal,
EuropeanJournalofEndocrinology,vol.158,no.3.

Recommendations

ManagementissuesofGOthat
shouldbeaddressedby
bothnonspecialists andspecialists

Referraltocombinedthyroideyeclinics
andinitialassessment

Referurgently
Symptoms
Unexplaineddeteriorationinvision
Awarenessofchangeinintensityorqualityofcolour
visioninoneorbotheyes
Historyofeye(s)suddenlypoppingout
(Globesubluxation)

Signs
Obviouscornealopacity
Corneastillvisiblewhentheeyelidsareclosed
Discswelling

Referurgently
Compressiveopticneuropathy(Dysthyroid
opticneuropathy)
Exposurekeratopathy cornealmelting
cornealperforation

Refernonurgently
Symptoms

Eyesabnormallysensitivetolight:troublesomeordeteriorating over
thepast12months
Eyesexcessivelygrittyandnotimprovingafter1weekoftopical
lubricants
Paininorbehindtheeyes:troublesomeordeterioratingoverthepast
12months
Progressivechangeinappearanceoftheeyesand/oreyelidsover the
past12months
Appearanceoftheeyeshaschangedcausingconcerntothepatient
Seeingtwoseparateimageswhenthereshouldonlybeone

Signs

Troublesomeeyelidretraction
Abnormalswellingorrednessofeyelid(s)orconjunctiva
Restrictionofeyemovementsormanifeststrabismus
Tiltingoftheheadtoavoiddoublevision

SmokingandGO

Managementofhyperthyroidismin
patientswithGO

Managementofhyperthyroidismin
patientswithGO

Othersimplemeasures
thatmayalleviatesymptoms

ManagementissuesofGOthat
shouldbeaddressed
inspecialistscenters

GradingseverityandactivityofGO

 Lidaperture

Severitymeasures

distancebetweenthelidmarginsinmmwiththepatientlookingintheprimaryposition,
sittingrelaxedandwithdistantfixation

Swellingoftheeyelids
Rednessoftheeyelids
Rednessoftheconjunctiva
Conjunctival oedema
Inflammationofthecaruncle orplica
Exophthalmos
usingthesameHertel exophthalmometer

Subjectivediplopia score

0=nodiplopia;1=intermittent,2=inconstant,3=constant

Eyemuscleinvolvement
ductions indegrees

Cornealinvolvement(absent/punctate keratopathy/ulcer)
Opticnerveinvolvement

bestcorrectedvisualacuity,colorvision,opticdisc,RAPD(absent/present),plusvisualfieldsif
opticnervecompressionissuspected

GradingseverityandactivityofGO

GradingseverityandactivityofGO

GradingseverityandactivityofGO

ManagementofmildGO

ManagementofmildGO

ManagementofmildGO

Takehomemessage
Earlydetectionandreferralto
ophthalmologist