Features of dysthyroid eye disease

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Although Werner's early "NOSPECS" classification of dysthyroid eye disease

Table 11.1 Assessment of common clinical features of dysthyroid eye disease (after Thyroid 1992; 2:235-6).

Figure 11.1 A 39-year-old woman with dysthyroid compressive optic neuropathy: (a) before and (b) after orbital decompression.

underlines the concept of a gradation of severity of the condition, it has largely been superseded by classifications based upon the degree of inflammation - such as that of Mourits or that of others (Table 11.1). A simple "activity score" may be assigned by awarding one point for each of retrobulbar pain, pain on eye movement, eyelid erythema, eyelid oedema, conjunctival injection, conjunctival chemosis, caruncular swelling, deteriorating vision, diplopia and worsening appearance; an activity score of 3 or more (out of 10) indicates active disease.

An objective deterioration in visual acuity, reduced colour perception, an acquired visual field defect, impaired visual-evoked potentials or corneal ulceration are signs of serious sight-threatening disease for which urgent intervention is essential.

Treatment of the thyrotoxicosis of Graves' disease tends to improve eye signs, although hypothyroidism after suppression of the hyperthyroid state may exacerbate ophthalmopathy and this should be avoided by regular blood tests during control of the thyroid gland. Recent evidence suggests that radio-iodine treatment for thyrotoxicosis may adversely affect ophthalmopathy and systemic


Clinical assessment



Extraocular muscles


Optic nerve activity score

Patient self-assessment

Maximal fissure width

Upper lid to limbus distance and lower lid to limbus distance

Exposure keratopathy assessed by Rose Bengal or fluorescein staining (indicates presence of absence of staining)

Binocular single vision in central 30° field (indicate presence or absence, with or without prisms) and one or more of the following measurement techniques: Maddox rod test; alternate cover test; Hess chart or Lancaster red-green test.

Optional: intraocular pressures, CT scan or MRI scan


(CT or MRI scan may also be used for measurement)

Visual acuity, fields and colour vision Sum one point for each of the following: spontaneous retrobulbar pain; pain with eye movement; eyelid erythema; eyelid oedema; conjunctival injection; conjunctival chemosis; caruncular swelling

Satisfaction with the following (indicate change of each with therapy, using a scale such as "greatly improved, improved, unchanged, worse, much worse"): appearance; subjective visual function; ocular discomfort; diplopia steroids during therapy may prevent exacerbation of the eye disease.

Although most patients with the clinical features of dysthyroid eye disease have abnormal thyroid function, some will be euthyroid and the clinical diagnosis may be supported only by raised levels of serum thyroid auto-antibodies.

Orbital imaging in dysthyroid eye disease (most readily with CT scan) tends to show enlargement of several extraocular muscles, the inferior and medial recti being affected most frequently, the superior and lateral recti less often and involvement of the oblique muscles being relatively rare. Other features include changes in the orbital fat and, with longstanding disease, changes in the thin

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