Laboratory diagnosis of TED
1- Biochemical investigations in diagnosis of Thyroid Eye Disease TED
• TSH
Low in hyperthyroidism
High in hypothyroidism
• Free T4
High in hyperthyroidism
Low in hypothyroidism
• In subclinical hyper- or hypothyroidism, free T4 will be normal, but the TSH will still low in hyperthyroidism and high in hypothyroidism respectively.
2- Immunological investigations in diagnosis of Thyroid Eye Disease TED
• Anti-TSH receptor :
>95% Graves’s and 40–95% TED
• Anti-thyroid peroxidase :
80% Graves’s and 90% Hashimoto’s
• Anti-thyroglobulin :
Diagnosis of Thyroid Eye Disease TED PowerPoint presentation:
Thyroid eye disease ( Graves Ophthalmopathy )
1. Thyroid Eye Disease Raed Behbehani , MD FRCSC
2. Thyroid Eye Disease • 1-2% of women , 0.5% of men • Female : Male ratio , 5:1 • Infiltration of immune effector cells and thyroid-antigen-specific T cells into thyroid and TSH receptors carrying tissues • TSHR is found on thyroid epithelial cells , adipocytes and bone cells. • Fibroblast activation is caused by inflammatory cytokines released by T-cells and macrophages.
3. Thyroid Eye Disease Pathology • Infiltration of connective tissue with mononuclear cells (lymphocytes, macrophages , plasma cells) • Activation of CD4+ and CD8+ T-cells and integration with B cells, plasmas cells and macrophages. • Release of pro-inflammatory cytokines. • Accumulation of GAG in the EOM and fat. • CD34 + fibrocytes key in the pathogenesis , • Antigen in orbit : Thyroglobulin • TSHR is found on thyroid follicles and orbital fibroblasts
4. Thyroid Eye Disease Systemic Signs and Symptoms • Symptoms : Hyperactivity , hear intolerance , palpitations , weight loss and gain (increased appetite) , Diarrhea . • Signs : Tachycardia , atrial fibrillations , tremor , goiter , warm moist skin, lid retraction and lag , exophthalmos. • Eye signs usually start within a year of hyperthyroidism (75%) • Occasionally eye signs start years later.
5. Thyroid Eye Disease Laboratory investigations • Endocrine : low or borderline TSH ,normal or elevated T4 , elevated T3, TSHR autoantibodies • T3 toxicosis . • T4 toxicosis (excess iodine intake) • Eleveated bilirubin , liver enzymes , ferritin (diagnostic confusion) • Microcystic anemia and thrombocytopenia.
6. TSHR Auto-antibodies • Antibodies that bind to TSH receptors. • Binding assay : measures both Thyroid stimulating and thyroid blocking antibodies • Cell-based assay : can distinguish thyroid stimulating and thyroid blocking antibodies by their effect on cyclic AMP production in cell lines. (more useful to measure activity and prognosis)
7. Imaging in TED • Enlargement of EOM, orbital fat expansion , increase lacrimal gland size. • CT is the study of choice (Bone and soft tissues)
8. CT in TED • For initial diagnosis and for planing for decompression surgery • Bone remodeling (medial wall) • Enlargement of EOM , lacrimal glands, anterior soft tissue swelling , prominent SOV maybe seen
9. MRI in TED • Quantitative and qualitative • Assess disease activity • Increased T2 in EOM – good response to XRT and steroids • Increased T2 in EOM – active stage ( high water content) • Low T2 in EOM- inactive fibrotic stage
10. Ultrasound in TED • A and B-scan • operator dependent • Normal muscle – low internal reflectivity • Active phase – lower internal reflectivity (swelling) • Fibrotic phase- irregular high reflectivity (scar)
11. Medical Management of Hyperthyroidism • Anti-thyroid drugs : thinoamides (PTU) , carbimazole , methimazole. • Thionamides inhibit synthesis of thyroid hormones. • Need 6-8 weeks to achieve euthyroid state • Side effects of anti-thyroid drugs : Skin rash , urticarial , arthralgia , Fever
Thyroid Eye Diseases Dr.Mohammad Dmour- PGY1 Supervised by : Dr.Sami Rezeq Ophthalmology Department- Islamic Hospital
Diagnosis of Thyroid Eye Disease TED videos:
Graves’ Disease – Hyperthyroidism – Everything You Need to Know – MADE EASY
Medical Institution
Diagnosis of Thyroid Eye Disease TED
