eMedicine Specialties > Ophthalmology > Orbit

Thyroid Ophthalmopathy: Differential Diagnoses & Workup

Author: Edsel Ing, MD, FRCSC, Assistant Professor, Department of Ophthalmology & Vision Sciences, University of Toronto: Consulting Staff, Toronto East General Hospital
Contributor Information and Disclosures

Updated: Apr 30, 2008

Differential Diagnoses

Cellulitis, Orbital
Cellulitis, Preseptal
Sarcoidosis

Workup

Laboratory Studies

  • Blood

    • In screening for thyroid disease, the combination of free T4 (thyroxine) and TSH (thyroid-stimulating hormone) or serum TSH (thyrotropin) are highly sensitive and specific. However, because of cost, some recommend initially only using the TSH to screen for thyroid disease.
    • Serum TSH (thyrotropin) is useful to establish a diagnosis of hyperthyroidism or hypothyroidism. Usually, the TSH is low in hyperthyroidism and high in hypothyroidism.
    • There is a confusing and inconsistent nomenclature for the various TSH receptor assays. Assays that measure the binding of TSH to a solubilized receptor are often referred to as TRAb (thyroid receptor antibody), TBII (TSH-binding inhibitor immunoglobulin), and LATS (long-acting thyroid stimulator) assays. Assays that measure the ability of immunoglobulin G (IgG) to bind to the TSH receptor on cells and to stimulate adenylate cyclase production have generally been referred to as the TSI (thyroid-stimulating immunoglobulin) assays.
    • Other blood tests that may be useful include calculated free T4 (thyroxine) index, thyroid-stimulating immunoglobulin, antithyroid antibodies, and serum T3 (triiodothyronine). The introduction of direct assays for TSH, free T4, and free T3 has superseded the usefulness of total T4 and T3 resin uptake testing.
    • Thyroid peroxidase antibodies and antibodies to thyroglobulin may be useful when trying to associate eye findings with a thyroid abnormality, such as euthyroid Graves disease.
    • The thyroid peroxidase test is also called the antimicrosomal antibody test and the antithyroid microsomal antibody test.
    • The antithyroglobulin test is also called the antithyroid antibody test.
    • The serum level of hyaluronan is not a sensitive indicator of its presence within the extraocular muscles.

Imaging Studies

  • Ultrasound
    • Orbital ultrasound can quickly confirm if the patient has thickened muscles or an enlarged superior ophthalmic vein.
    • The author of this article prefers other imaging modalities. 
  • CT scan and MRI
    • If the diagnosis of TAO can be established clinically, then it is not necessary to routinely order a CT scan or an MRI.
    • If the above studies are required, obtain axial and coronal views.
    • Neuroimaging usually reveals thick muscles with tendon sparing.
      • The inferior rectus muscle and the medial rectus muscle usually are involved.
      • Isolated rectus muscle involvement may occur in up to 6% of patients. In this subgroup of patients, the superior rectus muscle may be the most frequently involved muscle.
      • Isolated lateral rectus muscle enlargement without other evidence of muscle enlargement is uncommon in TAO but suggests another disease process (eg, orbital myositis).
      • Bilateral muscle enlargement is the norm; unilateral cases usually represent asymmetric involvement rather than normality of the less involved side.
    • Neuroimaging may show a dilated superior ophthalmic vein.
    • Apical crowding of the optic nerve is well visualized on neuroimaging.
    • MRI is more sensitive for showing optic nerve compression.
    • CT scan is performed prior to bony decompression because it shows better bony architecture.
    • Occasionally, the proptosis of TAO results in straightening of the optic nerve.

Histologic Findings

  • Lymphocytic cell infiltration
  • Enlargement of fibroblasts
  • Accumulation of mucopolysaccharides
  • Interstitial edema
  • Increased collagen production
  • Fibrosis with degenerative changes in the eye muscles

More on Thyroid Ophthalmopathy

Overview: Thyroid Ophthalmopathy
Differential Diagnoses & Workup: Thyroid Ophthalmopathy
Treatment & Medication: Thyroid Ophthalmopathy
Follow-up: Thyroid Ophthalmopathy
Multimedia: Thyroid Ophthalmopathy
References
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Further Reading

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Keywords

Graves ophthalmopathy, Graves' ophthalmopathy, thyroid-associated ophthalmopathy, TAO, thyroid-related eye disease, von Basedow ophthalmopathy, von Basedow's ophthalmopathy

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Contributor Information and Disclosures

Author

Edsel Ing, MD, FRCSC, Assistant Professor, Department of Ophthalmology & Vision Sciences, University of Toronto: Consulting Staff, Toronto East General Hospital
Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American College of Physician Executives, American Society of Contemporary Ophthalmology, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, North American Neuro-Ophthalmology Society, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Medical Editor

Jorge G Camara, MD, Chairman, Department of Ophthalmology and Otorhinolaryngology, Director of Fellowship Training Program, St Francis Medical Center; Associate Professor, Department of Surgery, University of Hawaii School of Medicine
Jorge G Camara, MD is a member of the following medical societies: American Academy of Ophthalmology and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal, and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic
Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience
Disclosure: Allergan - Botox Cosmetic Consulting fee Consulting; Quest medical - lacrimal balloons Honoraria Speaking and teaching

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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