Ocular Disease III - Thyroid & Rheumatology
Ocular Disease III - Thyroid & Rheumatology
 Study
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 Review All
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 Quiz!
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Most prevalent orbital dz? |
Thyroid eye dz (60-70%) |
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Ocular involvement in __% of thyroid dz, __ manifest signs. |
70-80%, 30-40% |
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(Hyper/Hypo)thyroidsm tends to "burn out" to quiescent stage after 1-3 yrs |
Hyper |
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Thyroid eye dz is commonly (unilat/bilat) |
bilat |
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Thyroxine is aka ___. |
T4 |
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T3 is aka... |
triiodothyronine |
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Top 3 signs of thyroid eye dz... |
1) Corneal exposure (lid retract) |
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T/F - Most T4 is free and unbound. |
False - 99.9% of T4 bound to TBG and other proteins (TBPA and albumin) |
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What happens to T4 in the peripheral tissues? What is the pharmacologic significance of this? |
Degraded to T3 Site of activity for oral anti-thyroid meds such as PTU |
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TSH from ___ stimulates ____, ___, and ___. |
ant pituitary, thyroid gland growth, hormone synth, release |
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TSH secretion promoted by ___, inhibited by ___. |
TRF (from hypthalamus) |
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What hormone inhibits TSH secretion? |
T4 (thyroxine) |
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State if incr or decr in Hyperthyroidism: |
1. TSH level = decr |
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State if incr or decr in Hypothyroidism: |
1. TSH level = incr |
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Thyroid hormone effects? |
Incr calorigenesis, protein synth, fat degredation, vitamin utilization. Also variety of changes in carb metabolism. Basically, weight loss b/c incr metabolic activity |
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Graves' dz = hypo or hyperthyroidism? |
hyper |
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Graves' dz mechanism in eye/orbit? |
Imm sys grabs orbital blasts in orbital fat, converts it to GAGS - causes taking up of water, thus puffiness & EOM swelling Also inflam causes edema |
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What is goiter? |
Enlarged thyroid, happens in hyperthyroidism/Graves' |
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Infiltrative dermopathy is a definitive sign of (hyper/hypo)thyroidism? |
hyper |
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Graves' dz demographic? |
Women 20-50 yo |
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When do the eye problems occur in Graves' dz? |
precede, coincide, or follow thyroid abnormality |
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T/F - Ophthalmopathy can occur alone in Graves' dz |
True - but rare |
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Graves' dz is an autoimm disorder with ___ producing immunoglobulins causing (insuff/excess) thyroid and hormone secretion. |
Beta lymphocytes, excess |
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What orbital dz can be assoc w/ pernicious anemia? |
Graves' dz |
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What is pretibial myxedema? |
Shiny, orange-peel like thickening of skin over lateral part of leg due to infiltration of MPS into dermis. Sx = itching. 5% Graves' dz. Highly diagnostic of Graves' dz. |
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Most common neoplasm of thyroid? Results in... |
Follicular adenoma, causes hyperthyroid |
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How does an ovarian tumor relate to thyroid dz? |
Ovarian tumors can produce thyroid hormone (Struma Ovarii), thus can cause hyperthyroidism |
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How does a testicular or placental tumor relate to thyroid dz? |
testicular or placental tumors can produce thyroid hormone, thus can cause hyperthyroidism |
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What is secondary hyperthyroidism? |
TSH-secreting tumor of pituitary, results in hyperthyroidism |
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What is Thyrotoxicosis Factitia? |
Self-administration of thyroid hormone beyond normal (dieting), causes hyperthyroidism |
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Glucocorticoid withdrawal or stress, parturition, and lithium therapy can cause (hyper/hypo)thyroidism? |
hyper lithium can also cause hypothyroidism |
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(Hyper/Hypo)thyroidism = weight loss |
hyper |
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(Hyper/Hypo)thyroidism = hyperactivity and insomnia but fatigue |
hyper |
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(Hyper/Hypo)thyroidism = heat intolerance? |
hyper |
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(Hyper/Hypo)thyroidism = velvety, warm, moist skin? |
hyper |
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(Hyper/Hypo)thyroidism = brittle, coarse hair? |
hypo |
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(Hyper/Hypo)thyroidism = oncholysis? |
hyper |
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(Hyper/Hypo)thyroidism = bradycardia? |
hypo |
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(Hyper/Hypo)thyroidism = constipation? |
hypo |
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(Hyper/Hypo)thyroidism = normal body weight? |
hypo (can also be incr) |
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(Hyper/Hypo)thyroidism = goiter? |
Either, hyper is usually, but hypo is sometimes present |
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What kind of reproductive changes occur in hyperthyroidism? |
Amenorrhea, oligomenorrhea, (gynecomastia in men) |
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(Hyper/Hypo)thyroidism = shortness of breath? |
hyper (high metabolism thus high O2 demand) |
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Most common Tx for Graves'? Mech? |
Methimazole/Propylthiouracil (PTU), block periph conversion of T4 to T3 |
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Methimazole/PTU can cause these side effects. Sx? |
Mostly rash. Also can cause agranulocytosis (rare). Sx = sore throat, fever |
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What Tx is appropriate for pregnant/nursing females with Graves'? What is NOT appropriate? |
PTU appropriate - does not cross placenta. Can also do surgery (ablate glands) Do NOT use radioactive iodine |
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High incidence of secondary hypothyroid state with this Graves' Tx... |
radioactive iodine (131 I) |
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Appropriate way to assess thyroid gland by palpation? |
Stand behind pt and move trachea to side, then let pt drink cup of water & palpate for nodule |
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Radioactive iodine can Tx Graves' but the side effects are... |
high incidence of secondary hypothyroidsm, 10-15% have exacerbation of ocular Sx |
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What Tx is good for the Sx of hyperthyroid? |
B-Blocker - makes sense b/c calms them down (hyperthyroid = high metabolism) |
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What is Von Grafe's sign? Assoc w/? |
Lid lag on downgaze, assoc w/ Graves' |
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Type I Graves' demographic? Involves... |
Mostly females. No myopathy, incr orbital fat, less proptosis; better prognosis when orbital fat removed |
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Type II Graves' demographic? Involves... |
Mostly older males, worse prognosis. (+) myopathy, EOMs swell and fibrotic. (+) orbital fat, removal not as helpful. Tx by break bone to make room for edematous EOMs |
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What is the worst (and preventable) risk factor for eye involvement of Graves'? |
Smoking |
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Summarize the Graves' classification of ocular involvement (Werner's Classification) |
NOSPECS classes: |
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Graves' Class 1 signs limited to... |
upper lid retraction, stare w/ or w/o lid lag and proptosis |
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Guanethedine is used for... |
causing ptosis in Graves' (to reverse lid retraction) |
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Rev-eyes is used in Graves' to... |
cause ptosis for Graves' pts (to reverse lid retraction) |
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T/F - Surgery is not indicated for Class 1 Graves' |
True |
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What drugs are used to induce ptosis in Graves' pts? |
Guanethidine, Rev-eyes, topical Timoptic, Botox |
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Class 2 Graves' involves... |
Soft tissue involvement - Sx excess lacrimation, sandy sensation, retrobulbar discomfort, photophobia. No diplopia |
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Your pt complains of excess lacrimation, photophobia. You notice slight edema in the lids and lagophthalmos. This must be Graves' Class... |
2 (Moderate) |
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Best Tx for Class 2 Graves'? |
Oral steroids (high dose 60-100 mg) - to rapidly reduce swelling |
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T/F - Topical, oral, and IV steroids are used in Graves' Class 2. |
False - Topical not helpful |
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T/F - Retrobulbar steroid injection is indicated for severe soft tissue involvement in Graves'. |
False - retrobulbar can exacerbate condition (incr proptosis b/c more fluid) |
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If you see proptosis greater than ___ mm, ___ mm inequality b/w eyes, or ___ mm progression, your pt is at Class 3 Graves'. |
23, 2, 2 |
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T/F - Diplopia occurs in Class 3 Graves'. |
True - possible due to proptosis |
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T/F - Botox is not useful for Tx proptosis in Graves' Class 3. |
True |
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Steroids are more helpful for Type (I/II) Graves'? |
More helpful for Type I (fat) vs Type II (muscle) |
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Orbital radiation is more effective for (acute/chronic) Class 3 Graves'? |
acute |
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What is useful for reducing orbital volume in Class 3 Graves'? |
Adrenergic blocking agents |
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Minimal Proptosis in Class 3 Graves'? |
21-23 mm |
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Moderate Proptosis in Class 3 Graves'? |
24-27 mm |
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Marked Proptosis in Class 3 Graves'? |
28 mm or more |
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2nd most commonly involved EOM in Graves'? |
MR |
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T/F - It is not appropriate to Tx Class 4 Graves' w/ prism. |
False - can use Fresnel prism |
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A-scan in Class 4 Graves' is useful for... |
looking for EOM thickness |
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B-scan in Class 4 Graves' is useful for... |
looking for EOM contour |
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When is surgery for Class 4 Graves' indicated? |
If stable after 6 mos |
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Stippling of the cornea is Class __ Graves' (be specific). |
5 (minimal) |
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Orbital decompression is indicated for what Graves' class? |
5 (corneal involvement) - for 2nd-3rd bout of keratitis; orbit is pushed back to allow lids to close Also for Class 6 - if steroid not working & VF not improving, to relieve ON choking |
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20% of Graves' pts can get this early corneal sign, even before thyroid manifests. Tx? |
SLK (redness @ limbus superiorly) |
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What causes Class 6 Graves'? |
Due to ON choking |
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Class 6 Graves' (Minimal)? |
Disc pallor or choking, or VF defect: 20/20-60 |
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Class 6 Graves' (Moderate)? |
Disc pallor or choking, or VF defect: 20/70-200 |
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Class 6 Graves' (Marked)? |
Blindness, NLP, vision worse than 20/200 |
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Order of surgical intervention in Graves'? |
Decompression, EOM surgery, then lid surgery (in this order) |
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5 step plan in Graves' Tx? |
1) Medical & supportive Tx |
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#1 cause of hypothyroidism? #2? |
#1 = Hashimoto's |
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Incr risk of Class 6 Graves' with... |
males, shallow orbits, smoking |
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Why are hypothyroid pts at higher risk for glaucoma? |
b/c produce hyaluronic acid |
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What thyroid dz mimics aging? |
Hypothyroidism |
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Hypothyroidism demographic? |
Older pts; incr female prevalence w/ incr age |
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(high/low/normal) TSH w/ (high/low/normal) free T4 is diagnostic of hypothyroidism. |
high, low |
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Pts w/ pituitary hypothyroidism show signs of (low/high) FSH and LH levels along with (low/high) sex hormone levels. |
low, low |
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What syndrome can mimic hypothyroidism in kids? |
Down's |
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Sacroidosis can cause (hyper/hypo)thyroidism? |
hypo |
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TB can cause (hyper/hypo)thyroidism? |
hypo |
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Sulfonamides can cause (hyper/hypo)thyroidism? |
hypo |
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Loss of lateral 1/3 of eyebrow is a sign of... |
hypothyroidism |
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(Hyper/Hypo)thyroidism = Menorrhagia? |
hypo |
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(Hyper/Hypo)thyroidism = paresthesia, numbness? |
hypo |
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(Hyper/Hypo)thyroidism = galactorrhea? |
hypo |
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(Hyper/Hypo)thyroidism = brittle nails? |
hypo |
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(Hyper/Hypo)thyroidism = alopecia? |
hypo |
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T/F - Can have normal TSH in hypothyroidism. |
True - in secondary hypothyroidism (can be low/normal/mildly elev) |
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(Hyper/Hypo)thyroidism = elevated cholesterol level. |
hypo Think weight gain? |
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(Hyper/Hypo)thyroidism = proteinuria? |
hypo |
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(Hyper/Hypo)thyroidism = low glucose and serum sodium |
hypo |
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Tx hypothyroidism? |
Levothyroixine (T4) |
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Coronary artery dz occurs in (hypo/hyper)thyroidism? Watch for this sign... |
hypo, watch for angina pectoris |
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(Hyper/Hypo)thyroidism = low pitched, hoarse voice |
hypo |
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SLE demographic? |
Black women, 15-40 |
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Procainamide and hydralazine can induce this autoimm dz. |
SLE |
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What describes this dz? Antibodies to DNA and other nuclear contents are formed. ANAs result in inflammation to glomerular basement membranes. |
SLE |
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A 30 yo black female patient comes in and you notice she is balding. She also is skinny, looks weak, and complains of muscle aches and arthritis. You suspect... |
SLE |
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Malar "butterfly" erythematous rash is characteristic of ___. Tx? |
SLE, Tx = steroids |
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SLE with manifestation limited to the skin is called... |
discoid lupus |
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Major cause of morbidity and mortality in SLE? |
Renal involvement (either HTN or kidney dysfxn) |
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Hematologic changes in SLE? |
anemia, leukopenia (decr WBCs), thrombocytopenia (decr platelets), clotting abnormalities |
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T/F - SLE can affect EOMs. |
True - neurologic involvement |
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Most common ocular sign of SLE? Tx for this? |
dry eye (KCS) - restasis useful |
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Most characteristic retinal abnormality in SLE? |
Cotton wool exudates |
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SLE is a vasculitis, thus you see these signs in the retina: |
Superficial hemes (flame shaped), retinal edema, pseudopapilledema, artery narrowing, A-V crossing abnormalities |
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Bulls-eye retinopathy is possible in SLE...why? |
Plaquenil causing macula toxicity (the bulls-eye). Plaquenil is used to Tx SLE |
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T/F - INO is possible in SLE. |
True |
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T/F - AION is possible in SLE. |
True |
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What tests are used to confirm SLE? |
ANA*, ESR, Ig electrophoresis, lupus erythematosus cell prep, Rh factor |
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(+) Anti-Ro, (+) Anti-La, and (+) ANA is suggestive of... |
SLE |
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Mycophenolate Mofetil is used for severe ___ but has problems with ____. |
SLE, liver issues |
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Anti-malarials e.g. hydroxychloroquine and plaquenil are used for these autoimm dz... |
SLE, Rheum Arth |
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Azasite is good for dry eye because... |
anti-inflammatory |
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Rheumatoid arthritis demographic? |
Post-menopausal women >60 yo |
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Rheum arth affects joints by... |
destruction of cartilage, adjacent bone, articular supporting structures |
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Your pt complains of stiffness and pain that is worse in the morning, especially at the fingers and wrists. You suspect... |
Rheum arth |
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Most freq affected joints in rheum arth? |
proximal interphalangeal and metacarpophalangeal joints |
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Rheumatoid nodules in rheum arth can occur... |
along extensor surfaces (arms) and within various organs (eye) |
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#1 ocular manifestation of rheum arth? |
KCS |
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Filamentary keratitis is assoc w/ these autoimm dz |
Rheum arth, Sjogren's |
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Most common scleritis type in rheum arth? |
Ant diffuse |
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This scleritis has the highest morbidity/mortality rate... |
necrotising |
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T/F - Scleromalacia perforans has a worse prognosis vs necrotising scleritis. |
False - vice versa |
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T/F - Topical steroids are contraindicated for necrotising scleritis |
True - must use oral |
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T/F - Scleromalacia perforans does not involve inflammation and is not painful. |
True |
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2nd most common scleritis in rheum arthritis? |
nodular |
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What test is highly diagnostic of rheum arth? |
X-ray of affected joints - articular cartilage destruction |
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Rheumatoid factor is more useful in (late/early) rheum arthritis. |
early |
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Whorl-like epithelopathy is assoc w/ this autoimmune dz (specifically a Tx used for this dz)... |
NSAIDs (rheum arth) |
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Chewing gum or frequent drinking is an adjunct Tx for... |
Sjogren's (decr dental caries) |
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What specific kind of tear layer deficiency is Sjogren's? |
Aqueous |
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Primary vs Secondary Sjogren's? |
Primary = eye, mouth, no connective tissue Secondary = eye, mouth, connective tissue |
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Sjogren's demographic? |
Older females |
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Sjogren's has an incr risk of this type of lymphoma... |
non-Hodgkin's |
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Parotid enlargment is involved in this autoimm dz... |
Sjogren's |
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T/F - Sjogren's involves loss of taste and smell. |
True |
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T/F - Corneal ulcers are possible in Sjogren's |
True |
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#1 connective tissue dz assoc w/ Sjogren's? |
Rheum Arth |
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Polymyositis and Polyarteritis are assoc w/ this autoimm dz |
Sjogren's |
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(+) Anti-Ro, (+) Anti-La, and (-) ANA is suggestive of... |
Sjogren's |
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To help incr salivary and lacrimal gland secretion in Sjogren's, you can use... |
Oral Pilo (Salagen) |
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T/F - Can suck on candies to encourage salivation as adjunct Tx for Sjogren's. |
False - avoid sugar containing candies Can chew gum for dental caries |
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Scleroderma is aka |
systemic sclerosis - "hard skin" |
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The 2 forms of Scleroderma? |
Limited = hands + face |
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Pathogenesis of Scleroderma? |
Primary fibrotic process or vasculitis secondarily promoting deposition of incr amts of collagen |
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Scleroderma demographic? |
Middle-aged women |
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T/F - Limited systemic sclerosis is more prevalent vs diffuse. |
True Diffuse = 20% |
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Raynaud's phenomenon is typical of this connective tissue disorder |
Scleroderma (both diffuse and limited) |
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Polyarthralgia is typical of this connective tissue disorder (be specific) |
Diffuse Scleroderma |
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T/F - Intestinal hypomotility occurs in limited systemic sclerosis. |
False - diffuse type |
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Fibrotic changes of skin and internal organs, intestinal hypo-motility, pulmonary fibrosis, HTN, renal failure, and myopericarditis are characteristic of... |
Diffuse Scleroderma |
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Crest syndrome is aka... |
Limited systemic sclerosis: |
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Skin tightening is limited to distal extremities in this form of Scleroderma |
limited systemic sclerosis |
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Which of the two Scleroderma types have a better prognosis? |
Limited systemic sclerosis |
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Describe how the lids look in Scleroderma |
Lose elasticity (become tight), thin, smooth, shiny, retracted Involves ptosis [says this too despite retracted?] and lagophthalmos |
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Retinal signs in Scleroderma? |
CWS, hypertensive changes accompanying renal dz |
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T/F - Scleroderma can be assoc w/ Sjogren's. |
True |
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T/F - (+) ANA is helpful in Dx Scleroderma? |
True - 90% positive, but must DDx vs SLE |
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Anticentromere antibody is more likely in (limited/diffuse) scleroderma? |
limited |
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Tx Raynaud's phenomenon? |
Nifedipine (Ca channel blocker) |
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Penicillamine is used to Tx... |
Rheum arth and scleroderma |
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What is used to Tx the esophageal reflux in scleroderma? |
Omeprazole (proton pump inh) |
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Digital ulcers Tx in scleroderma? |
Iloprost |
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Raynaud's is exacerbated by... |
cold |
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T/F - Smoking cessation is an adjunct Tx for Scleroderma |
True |
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What dz is often assoc w/ Polymyalgia Rheumatica? |
Temporal arteritis |
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Temporal arteritis demographic? |
Older folks (women slightly more than men) |
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Pain and stiffness of the shoulder and pelvic girdle lasting 1 month or more w/o any other explanation is characterized by... |
Polymyalgia rheumatica |
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T/F - Temporal arteritis assoc w/ malaise, night sweats, weight gain |
False - weight loss/anorexia |
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T/F - Temporal arteritis has (+) APD |
True |
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Why is Temporal arteritis an ocular emergency? |
b/c AION - good chance that other eye will go too within 24-72 hrs without steroids |
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What vessel is involved that causes VF loss in Temporal arteritis? |
Short post ciliary a. |
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What is an early visual sign of Temporal arteritis? |
color vision loss |
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T/F - IV nerve palsy possible in Temporal arteritis |
False - VI nerve |
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What is considered (+) Temporal arteritis in ESR? |
>50 |
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Calculate ESR for men? |
age/2 |
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Calculate ESR for women? |
age+10/2 |
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What two tests have high diagnostic value in Temporal arteritis? |
ESR and C-reactive protein |
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Gold standard of Temporal arteritis testing? |
temporal artery biopsy |
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When is it appropriate to do a temporal artery biopsy for Temporal arteritis pts? |
within 1 wk of starting steroids |
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Tx Temporal arteritis? |
IV steroids (Methylprednisone 250 mg q6h x12), then switch to oral steroids (prednisone 80-100 mg PO daily for 4 wks) |
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Causative agent of Lyme dz? |
spirochete (Borrelia burgdorferi) transmitted by tick |
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Erythema Chronicum Migrans (ECM) is diagnostic of... |
Lyme dz (early skin lesion) |
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Erythema Chronicum Migrans begins as... |
red maculae or papule, 1 wk after tick bite |
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Erythema Chronicum Migrans Sx? |
Summer flu-like Sx (chils, fatigue, fever, HA, stiff neck, myalgia, arthralgia); neurologic abnormalities possible; arthritis can occ wks to mos after ECM |
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Two main ocular signs of Lyme dz? |
Bell's Palsy and Pars Planitis |
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Main diagnostic tests for Lyme dz? |
IFA, ELISA, Western Blot Best test = PCR but often not ordered |
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Tx Lyme dz in adults? |
#1 = Tetra or Doxy All about 21-28 days dosing |
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Lyme dz stages? |
1) Days-weeks = ECM (95%) |
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Your pt presents with bilateral ptosis, edematous skin on the lower lid, and lethargy. Dx? |
Sleepiness secondary to overstudying ocular disease!!!!!! |
