Game 18
Solve
in
1
You walk out of your consultation to a scare. Someone staring right at you.
Oh no that's your patient. Why is he staring at you?
His eyelids fully retracted, sclera showing, eyes bulging.
​
You notice that he is sweating quite a bit.
"Can you turn on the aircons?"
It's like 19 degrees celcius today. You reluctantly throw on another layer and turn on the air conditioning in the consultation room.
Solve
in
2
You show him the seat and notice that his eyelids only seem to close a bit when he looks down.
You first test visual acuity, to which you obtain 6/20 approximately in both eyes.
You decide to observe ocular motility. He can seem to only look up. All other directions are considerably more difficult for him.
​
You begin to start suspecting diseases. Your differential diagnosis begins:
- Cellulitis?
- TED?
- Varicies?
- Fistula?
- Encephalocele?
Last
chance
You do a VF test on him using a red-dot, to which there seems to be a field constriction.
​
You know your patient has a history of smoking which contributes to your suspicions.
You give him moisture shields to protect his eye from secondary infections, and warn him to not smoke. You advise him to sleep slightly sitting up, and then you refer him to a doctor.
The
answer
Thyroid Eye Disease (TED).
- 60% will manifest from Grave's Disease
- Soft tissue involvement will occur, causing pre-orbital swelling and some chemosis
- Eyelid retraction occurs due to the fibrosis of the levator muscle, and excess simulation of the Muller's muscle. The consequence is a staring effect with exposed sclera and eyelid closure lag
- Proptosis occurs bilaterally but asymmetrically, and can increase exposure keratopathy, hence the moisture shield. This is untreatable without surgery 70% of the time. Leads to diplopia and decreased VA
- Ophthalmoplegia occurs, in which the invasion of inflammatory cells in the EOMs (primarily inferior and medial rectus) will cause it to inflate near the apex. This will be painful, and lead to an inability to look around
- Optic Neuropathy follows from the inflated EOMs, which will apply pressure on the nerve, leading to colour deficits and VF deficits
- Management usually carried out by doctors due to surgery which may need to remove orbital walls. Endocrinologists also involved, and may need systemic steroids and radiotherapy.
- Can alleviate diplopia with prisms. Can alleviate ophthalmoplegia with botulinum toxin. Can alleviate eyes with moisture shields, punctal blockage and eyelid taping. Can help by recommending AWAY from smoking.