Thyroid Eye Disease and Cataract

Cataract in patients with thyroid disease

One needs to recognise that a patient presenting with cataract may have what is called thyroid eye
disease and that may need treatment before cataract surgery is attempted

Thyroid Eye disease

A condition in which eyelid retraction, proptosis, conjunctival injection, conjunctival chemosis,
corneal xerosis, extraocular muscle infiltration and fibrosis , compressive optic neuropathy are the
common manifestations
It is the most common cause of bilateral proptosis in adults

Types
A) Type 1
younger age group, whiter eyes with proptosis.  Inflammation in orbital fat not muscles.
B) Type 2 older patient with red eyes, severe sight threatening disease and usually tobacco chewers

Rundle staging and treatment-4 grades

to record the severity of  the ocular involvement4.

Grade 1 (mild) ophthalmopathy can present with ocular discomfort, transient oedema and mild
proptosis (Rundle a). The duration is typically two to four months and it normally resolves with no
sequelae.

Active phase treatment –
Patients with mild ophthalmopathy (Rundle a) are treated conservatively by

a) Lubrication with topical tear supplements and

b) Non-Steroidal Anti-Inflammatory Drugs (NSAID).


Grade 2 (moderate) ophthalmopathy includes eyelid retraction, conjunctival oedema, ocular ache
and moderate proptosis (Rundle b).

Treatment of Moderate cases with ocular discomfort and eyelid dysfunction (Rundle b)

Oral NSAID for 4-8 weeks (e.g. diclofenac 50mg tds).

Optional is oral steroids (e.g. 10-20mgprednisolone for 4-6 weeks)












Grade 3 (marked) ophthalmopathy presents with ocular motility disturbance with diplopia, chemosis
and marked proptosis (Rundle c). This  develops over six to twelve months and often leads to
persistent diplopia and proptosis.

Patients with marked disease presenting with active diplopia (Rundle c) are treated with

Oral prednisolone (starting with 0.5-1 mg/kg for 4 weeks and then tapering down over a further 8
weeks).

Steroid-sparing agents such as azathioprine 50-150 mg/day or cyclosporin A, 5-7 mg/kg for 4-12
months are used in the treatment of complex cases with persistent diplopia.

Some patients may require immunosuppression for up to two years.

Orbital radiotherapy is an option for this group but is somewhat controversial.


Grade 4 (severe) ophthalmopathy presents with optic nerve dysfunction with reduction of colour
vision and visual acuity loss (Rundle d).

Treatment in severe cases with optic nerve dysfunction (Rundle d)

larger doses of intravenous steroid may be given (0.5-1 gram/day of methylprednisolone for 3-5
days) followed by 1mg/kg oral steroid and/or a steroid-sparing agent. This may need to be
continued for several months.

In cases of poor response 10 sessions of 200cGy orbital radiotherapy should be considered.

In cases of persistent nerve compression, surgical orbital decompression with immunosuppression
cover may be necessary6.







References

1) Clauser L, Galie M, et al. Rationale of Treatment in Graves Ophthalmopathy. Plastic &
Reconstructive Surgery. 108; 1880-1894, December 2001.
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Implants: Four-Year Experience. Opthalmic Plastic and Reconstructive Surgery. 19; 38-45, January
2003.
3) Gliklich RE. Endoscopic Orbital and Optic Nerve Decompression. Minimally Invasive Surgery of
the Head, Neck, and Cranial Base. Phillip A. Wackym, Dale H. Rice, Steven D. Schaefer edd.
Lippincott Williams & Wilkins. C. 2002. pp. 319-324.
4) Graham SM, Brown CL, et al. Medial and Lateral Orbital Wall Surgery for Balanced
Decompression in Thyroid Eye Disease. Laryngoscope. 113; 1206-1209, July 2003.
5) Holt JE, Holt GR. Surgery for Exophthalmos. Head and Neck Surgery – Otolaryngology 3rd
Edition. Byron J. Bailey, ed. Lippincott Williams & Wilkins. C. 2001. pp. 2151-2163.
6) Metson R, Samaha M. Reduction of Diplopia Following Endoscopic Orbital Decompression: The
Orbital Sling Technique. Laryngoscope. 112; 1753-1757, October 2002.
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Laryngoscope. 108; 1648-1653, November 1998
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2005]; Available from http://www.emedicine.com/radio/topic485.htm.
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North Am. 2002; 15(1):113-9.
10)Marcocci C, Bartalena L, Tanda ML, et al: Comparison of the effectiveness and tolerability of
intravenous or oral glucocorticoids associated with orbital radiotherapy in the management of severe
Graves’ ophthalmopathy: results of a prospective, single blind randomized study. J Clin Endocrinol
Metab. 2001;86:3562-3567.
11) Prummel MF, Wiersinga WM: Smoking and the risk of Graves Disease. JAMA. 1993; 269:479-482
12) Prummel MF, Mourits MP, Berhout A, et al: Prednisone and cyclosporine in the treatment of
severe Graves’ ophthalmopathy. N Eng J Med. 1989; 321: 1353-1359.