A 55-year-old male develops complaints of sudden onset persistent diplopia while looking ahead since a week. On questioning, he lets us know that he has had similar complaints of diplopia intermittently, especially on waking up for the last two months which did not interfere with his daily activities. He has also noticed complaints of redness in the right eye and a feeling of grittiness in both eyes. His wife adds that it seems like his eyes are ‘popping out’ of his sockets. He has noticed weight loss of around 8% over the last few months with insomnia and fatigue, both of which he attributed to his current change of his boss at work and hence was not investigated for. His sister has primary hypothyroidism and is on levothyroxine supplements. He is a smoker (20 pack years). On examination, he is well built, with a BMI of 26 kg/m2. He appeared anxious, has a pulse rate of 100 bpm, blood pressure of 150/90 mm Hg, warm moist palms, has fine tremors of extremities and a diffuse goiter with no bruit. Eye examination reveals proptosis both eyes (R > L). Lateral movement of the right eye is restricted to 30° from midposition. Clinical activity score was right eye 4/7 (conjunctival redness, pain on movement, chemosis and swelling of the eyelids and the left eye 3/7 (pain on movement,conjunctival redness and chemosis). No dermopathy or nail changes noticed.
Investigations revealed a normal hemogram with normal total and differential leukocyte count. TSH <0.001 μIU/mL, free T4 80 ng/dL. Technetium uptake scan shows diffuse increased uptake over the entire gland. A diagnosis of Graves’ disease with moderate-to-severe, clinically active ophthalmopathy is made.
How is severity of Graves’ ophthalmopathy assessed?
Medicine
Severity of the Graves’ ophthalmopathy is assessed using these parameters like optic nerve status (visual acuity), corneal exposure, diplopia, proptosis, soft tissue involvement and lid retraction as detailed in the Table 7.1. The severity is graded as sight threatening, moderate-severe and mild. Sight threatening grade involves severe corneal involvement and decrease in visual acuity involving optic nerve compression and is an emergency requiring immediate intervention like intravenous steroids for a short duration and if no improvement is documented, surgical decompression of the orbit. Moderate-to-severe ophthalmopathy is where is no corneal or optic nerve involvement but proptosis, diplopia, soft tissue involvement and lid retraction are present which may interfere with activities of daily living of the patient. Mild ophthalmopathy is when the ophthalmopathy has only a minor impact on the life of the patient.
need an explanation for this answer? contact us directly to get an explanation for this answer