Grave’s Ophthalmopathy

SUSY FATMARIYANTI
DELFITRI LUTFI, HENDRIAN D. SOEBAGJO

DEPARTMENT OF OPHTALMOLOGY FACULTY OF MEDICINE UNIVERSITAS AIRLANGGA/

ACADEMIC GENERAL HOSPITAL DR. SOETOMO
Clinical Significance
✓ 25-50% of patients with Graves’ disease develop GO without any
predictive factor

✓ Ocular disorder usually appears

After
Simultaneously Thyroid disease
May precede
Graves Ophthalmopathy

 Terminology : also known as Thyroid Eye Disease

 Autoimmune disease
 Affecting thyroid, orbits, and skin
 Prediction of Graves’ evolution to GO is difficult and limits early
treatment

• Why only orbital fibroblast, orbital adipose tissue, and medial and inferior rectus muscles are
more often affected
• Possibility to have unilateral orbital case
• Great variety of clinical presentation
Etiology

Soebagjo HD., 2015

Patogenesis

Bahn, 2010; Soebagjo HD., 2015

 Among patient with GO

Symptom Graves hyperthyroidism

Primary hypothyroidism
Hashimoto thyroiditis
90%
1%
3%

and Euthyroid

Clinical Features
6%

Sign
Eyelid retraction (unilateral or bilateral) : 90%
- Retraksi kelopak mata atas 75%
- Lid lag pada posisi down gaze 50%

Exophthalmos 60%
Rsstrictive extraocular myopathy 40%
Optic nerve disfunction (unilateral or bilateral) 5%
With all sign (eyelid retraction, exophtalmos, optic nerve dysfunction, extraocular muscle disorder, and 5%
hyperthyroidism)
EUGOGO
classification :
Symptom
Orbital pain 30%
1. Sight treathening
Diplopia 17%
GO
Lacrimasi atau fotofobia 15%-20%
2. Moderate or severe Blurred vision 7.5%
GO Vision deterioration related optic neuropathy < 2%
3. Mild GO Other Symptom
Pretibial myxedema and acropachy 4% dan 1%

Myasthenia gravis < 1%

Ancilary Test

 Blood Test
 Imaging
Nature of disease

Rundle’s Curve
Severity VISA Classification

Clinical Activity Score

Management
 B-Cell
RITUXIMAB
T3 + T4 ↑
T-Helper Orbital Fibroblast
ABATACEPT

MHC CD4+
Class II
Thyrotropin
Receptor
T-Cell
Receptor
MTX
Genetic predisp Plasma B-Cell Anti Thyrotropin
IL-6 IGF1-R
trigger Cell RAPAMYCIN
Receptor Ab
Trigger T-Helper
ETANERCEPT
IFN-Ɣ, TNF
smoking? Anti Thyrotropin
Receptor Ab ↑↑ DZNEP

Orbital adipocytes PPARˠ

ADIPOGENESIS
ETANERCEPT
T-Cell
INCREASE FAT MTX TGF-B
ORBITAL VOLUME TNFα
FAT REMOVAL
SURGERY
LEUKOREGULIN
IL--1β
Hyaluronan PIRFENIDONE
INFLAMMATION PGE2
PENTOXYFILLENE,
Extraocular muscle ETANERCEPT,
CORTICOSTEROID, H89
CYTOSTATIC
INCREASE MUSCLE Macrophage
SIZE
SWELLING IL-1
MTX
STRABISMUS
EO-MUSCLE SURGERY
RESTRICTION Myofibroblast
ORBITAL DEC.
SURGERY

EYELID
RETRACTION FIBROSIS
EYELID RETRACTION
PROPTOSIS SURGERY
Soebagjo HD., 2015