MDNews - Cleveland-Akron-Canton

++ + ++ + ++++++++++++++++++++++++++++++++++ CLINICAL: OPHTHALMOLOGY ++++++++++++++++++++++++++++++++++ + + The Most Commonly Undiagnosed Common Eye Disease? By David S. Bardenstein, MD Associated Eye Disease: ism, hypothyroidism and even thyroid tumors. TED has a broad spectrum of man- ifestations ranging from minor alterations in eyelid structure through ocular surface disorders, myopathy causing double vision, exophthalmos and in the most severe cases blindness. It can be extremely disfi guring and can lead to extensive personal and societal cost due to disability and need for extended health care. Estimates of dysthyroid conditions T incidence in the U.S. are 4.5 million people. Combined with estimates of TED incidence of up to 50% that leaves more than 2 million Americans potentially at risk of TED. Estimates of the number of patients who are referred "late," i.e. after the disease is well established, by members of the International Thyroid Eye Disease Society (ITEDS) ranged from 50-85% making it one of the most striking examples of a recognized condition whose diagnosis is delayed. Reasons for the delay in diagnosis include failure to recognize that TED can affect anyone of any ethnic derivation from childhood to the aged and that, as an autoimmune condition related to but distinct from the dysthyroid state, it can occur in patients with normal T3 and T4 levels, and there is no truly diagnostic or prognostic biomarker for TED. The breadth and signifi cance of symptoms and fi ndings are often underappreciated as well. Recent findings have also helped HYROID ASSOCIATED EYE Disease (TED) is a condition associated with a range of primary thyroid problems including hyperthyroid- explain the delayed diagnosis of TED. A majority of TED patients have been shown to have concurrent eyelid and periorbital abnormalities which can cam- oufl age the fi ndings of TED, especially exophthalmos and lid retraction. Until the recent invention of a simple handheld instrument for detecting and measuring diplopia there was no method for all providers to identify diplopia. TED can present as lid retraction, ptosis (contralateral), exophthalmos, diplopia, restricted eye motion, dry eye, tearing, decreased vision, headache, pulling of the eyes, corneal ulcer, eye pressure, head tilt or turn, foreign body sensation, frequent blinking, elevated intraocular pressure, red eyes or even a vague sensation that something is "not right" with the eyes. Diplopia in the presence of myopathy may be denied if it is suppressed by the brain. Diagnosis of TED is challenging due to the absence of a diagnostic biomarker. Routine thyroid studies are often normal. Antibody studies are only correlative but critical, and there is not one that is always indicative so multiple antibodies should be obtained. Diagnosis involves combin- ing the clinical and laboratory data with imaging studies for fi rmest diagnosis. Due to the potential for camouflage, clinical exams should be performed by caregivers capable of sorting out confounding conditions. Management of TED can range from symptomatic care in mild cases to medical and radiotherapeutic sup- pression of inflammation to multiple surgeries in severe cases. Earlier diag- nosis can lead to reduced need for serious intervention. New approaches to immunosuppression including use of newer non-steroidal agents and B-cell depletion with monoclonal antibodies are showing promise in the drive for medical treatment of TED. New techniques in orbit surgery are leading to more effective results with less complications. In the old paradigm, patients had their dysthyroid state treated rapidly, and treatment of the TED was deferred until this was done. Currently, concern about complications of treating the dysthyroid state rapidly have led to long delays in ophthalmologic management of the eyes. Patients are best referred as soon as the diagnosis is suspected. Referral to eye care providers with a comprehensive understanding of TED is critical as well. There is nothing more disheartening to patients and referring physicians than to be told that a truly functional problem is "only cosmetic" or nonexistent. Serial evaluation is important as well since the onset of TED can precede or follow thyroid disease by years. Advances in the diagnosis, patho- physiologic understanding, medical and surgical treatment of TED offer great potential benefi t to these patients. David S. Bardenstein, MD, is the Director of Ocular Oncology and Pathology at University Hospitals Eye Institute. He also serves as a Professor of Ophthalmology at the Case Western Reserve University School of Medicine. n MDNEWS.COM SEPTEMBER-OCTOBER 2011 MD NEWS Cleveland-Akron-Canton | 39

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