|Year : 2013 | Volume
| Issue : 3 | Page : 185-186
Beyond a typical thyroid eye disease
Mohsen Bahmani Kashkouli
Eye Plastic Unit, Eye Research Center, Rassoul Akram Hospital, Tehran University of Medical Sciences, Tehran, Iran
|Date of Web Publication||9-Jul-2013|
Mohsen Bahmani Kashkouli
Eye Plastic Unit, Rassoul Akram Hospital, Sattarkhan-Niayesh St., Tehran 14455-364
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kashkouli MB. Beyond a typical thyroid eye disease. Middle East Afr J Ophthalmol 2013;20:185-6
Thyroid eye disease (TED) is an inflammatory orbital disease of autoimmune origin with the potential to cause severe functional and psychosocial effects.  TED is mostly and typically a bilateral (B-TED) disease, associated with hyperthyroidism (Hr-TED), and presenting with eyelid retraction, proptosis, and myopathy . Atypical forms are, however, being identified as awareness and diagnostic techniques improve.
Unilateral presentation of TED (U-TED) has recently been reported to include approximately 10% of TED cases.  U-TED and B-TED were not significantly different with regards to demographics, type of thyroid disease, associated findings, severity and activity of TED.  Whether there are greater (number or sensitive) receptors for the auto antibodies, more apoptosis  and/or greater expression of eicosinoids  in one orbital tissue, is a subject of future studies. In fact, the systemic nature of TED (similar to ocular and orbital metastasis in cancer) makes it difficult to explain why pure unilateral disease occurs at all. Perhaps there is time interval between switching from unilateral to bilateral TED, which requires further investigation in a cohort study. Similarly, the possibility of subclinical TED instead of U-TED remains unanswered and warrants future long-term cohort studies.
Traditionally, hypothyroid associated TED (Ho-TED) was considered a milder form of Hr-TED, thought to present in less than 1% of TED cases. Recently, Ho-TED has been reported in 7.5% of all TED cases with the same demographics, clinical characteristics, severity and activity scores as Hr-TED.  These observations imply that both groups represent the same category of eye disease. Possible explanations would be different states of hypo- and hyper-thyroidism at different times due to the possibility of spontaneous transition and/or
change of blocking antibodies to stimulating antibodies. Despite several reports over the last 50 years, Ho-TED is not very well explained, which may have led to an underestimation of prevalence.
Ocular surface dysfunction (OSD) may be the first manifestation of TED (occult TED), whereby, unlike keratoconjunctivitis sicca, the dry eye symptoms are attributed to underlying ocular surface inflammation rather than dryness.  Absence of eyelid retraction and proptosis and a good response to topical anti-inflammatory medications imply that the early manifestation of TED with OSD is a form of generalized inflammation which may affect ocular surface, eyelid, extra-ocular muscle and other tissues. TED, therefore, needs to be considered in the differential diagnosis of an OSD.
Alternately, patients with TED may simultaneously have other medical diseases (TED Plus) including orbital lesions, orbital metastasis, and carotid-cavernous fistula during the course of TED or these disorders may masquerade  as TED.
Appropriate management of TED decreases the rate of irreversible sequelae and, most importantly, improves the patient's quality of life.  Therefore, in the management of patients with TED, it is important to consider the following conditions beyond a typical TED presentation:
- Atypical TED presentations i.e. U-TED and Ho-TED.
- Occult TED in ocular surface dysfunction symptoms.
- Simultaneous occurrence of TED and other orbital and eye diseases (TED Plus) in the course of TED management.
- TED-like masquerading conditions such as lymphoma, metastasis, and fistula.
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