we are live good evening all welcome to if focus online the 363rd episode 38th in the oculoplasty module today we have with us our very own Dr rakar from Nar netralaya Bangalore to speak to us on thyroid ey disease the diagnosis clinical radiological evaluation and its grading Dr rakar has her mbbs from the father mu Medical College and Hospital Mangalore and a masters in oftalmology from the topala national Medical College b b l n Hospital Mumbai she's a fellowship in oculoplastic ocular oncology from center forite with Dr haava and uh as a Continuum to it at wi Hospital Philadelphia USA under the legendary Dr Carol and Jerry Shields she's currently a consultant at Nar netral Bangalore she's co-author 28 chapters of Dr hona on various topics including retinoblastoma orbit and oast team she's the recipient of numerous Awards and to name a few are the aios and oo Platinum award the APO Achievement Award the apos pradep SW Award Best paper award in ular pathology ular oncology at the AOS 2019 OPI gold medal for the first place in quiz at OPI 2018 International of thalmic hero award at AOS 2017 in jaur best poster award in OC pathology for physical poster at a 2017 best paper award for scientific paper at ocular oncology Master Class 2017 with Dr K sh in Hyderabad over to you Ma'am for tonight's lecture thank you Dr subba so much for the introduction um let me just so my slides are visible uh not currently ma'am once you begin to screen share just a minute yeah is that good yes uh can you have it in the slides share view m this is in slide share view uh this is ma'am can you stop share for a minute yeah okay uh just click on the green button screen share once and on the popup just click the blue button don't select anything just click the green button and then the blue button yeah done now put it in slid show okay still not there ma um probably in the checklist box there's a presenter's view so you can just untick that box on the right hand side yeah no it's not on The presenter's View just a moment it's actually in the presenter yeah so uh there where you can see the um on the task bar where it is help right below that is the Monitor and then the presenters view you can untake that presenters view box this is on the zoom um platform no no no on the on on your on your PP on my PP okay just below the help and view there is there is just above your picture there is there is the last one below below that just that yeah is this good now you can you can just slides share again just do this screen share again so sorry for the yeah is this good uh not yet there Mom so could you help s it I have done uh just close the presentation and start again M okay just close it once and then start and when you do the share please don't select the presentation just just on the on the popup just click on the entire screen rather than selecting the presentation okay the popup that comes it has to be the complete screen First Option left hand side and then click the blue button yeah done now try to is this good uh it still shows the same thing Ma'am why is this happening um Dr this just stop share for a minute okay uh just click on this green button once we'll this is the last once when the popup comes on and there is there is boxes on left hand side entire screen so on the popup there is just entire screen okay yes and then do the Blue Button see there's no Blue Button which is the share button the share button the share button after you selected the screen it's not in blue right now unfortunately yeah it's okay it's okay doesn't matter just click on the share button yeah it's not sharing when I click once you selected the once once you selected the screen it should it should share you selected the screen option we can yeah the presentation just open the presentation now or we can continue with with with the same way ma' we have to just open your presentation now yeah just put it on screenshot perfect my God that was quite a lendy thing okay anyways sorry for all the technical glitches so as Dr subba mentioned I'll be talking on thyroid ey disease so thyroid disease is a very vast topic and very tactfully this has been designed as a three-part lecture Series so the first part of the lecture that is the clinical Radiology iCal diagnosis and uh the grading system of thyroid disease is something that I'll be discussing with today this will be followed by the next two lectures by Dr hona and DRS Goldberg and rootman uh in the next two parts that will deal with the medical and the surgical management so thyroide disease is also known as Graves orbitopathy this is because of its close association with Graves disease so interchangeably can use stad or go uh in where uh uh context uh so as we all know the most common cause of thyroid ey disease is uh uh I mean most common cause of bilateral proptosis is uh thyroid ey disease as also it is the most common cause for unilateral proptosis so what is thyroid disease basically it is an inflammatory orbital disease so there is an inflammation in the orbit that is induced by this uh thyroid Association antigens so there are lot of fiberblast which are present in the orbital tissues naturally occurring and when these get activated and why these get activated I'll be eventually following it up in the next slide but these fiop blast which are naturally occurring in the orbital tissues when they get activated they generate a lot of glycosaminoglycans and these glycosaminoglycans get deposited in the orbital tissue and they cause two important things one is all orbital expansion that is increased orbital volume that leads to proptosis and optic neuropathy and also it causes compression of orbital structures mainly there is impaired Venus drainage that leads to periorbital edema chosis and this compression can also lead to optic neuropathy now like I said what activates these naturally occurring fibroblast into a glycos amoly glycan producing fibroblast is that there are certain triggers these triggers are not in any individual any and every individual it happens in those who are susceptible and those who have autoimmune condition okay so Graves disease as we know is an autoimmune condition and thyroid ey disease which is closely associated with graes disease is also an autoimmune condition and what are these trigger factors trigger factors can be endogenous or exogenous endogenous factors are non-modifiable risk factors and this can be genetic or hereditary increased age or male sex these are unmodifiable risk factors what are exogenous or modifiable risk factors are smoking High uh serum thyrotropin antibodies thyroid dysfunction and treatment of thyroid disorder with radioactive iodine so these are the modifiable risk factors and smoking is considered as the most modifiable risk factor and it is very very important that the history of smoking is included in any individual presenting with thyroid ey disease so when we talk about thyroid function and thyroid ey disease you must remember that not every individual is either hypothyroid or hyper thyroid going by statistics only 30% of the individuals are actually hyper thyroid 30% are hypothyroid and about 40% % of the individuals are U thyroid at the time of diagnosis of thyroid ey disease but going forward in the future these U thyroid individuals about 50% of them eventually get converted into either hyper or hyper thyroidism and hence even uh when an individual is noted to be U thyroid it is very important that you monitor the thyroid function every 3 to six monthly to detect the presence of any thyroid disregulation so thyroid ey disease one must remember that it is a clinical diagnosis it is not based on whether the T3 T4 TSH or anti thyroid antibodies are raised or lower no basically thyroid ey disease is a clinical diagnosis firstly so you must remember that these are there are unique clinical signs associated with thyroid ey disease and most of these clinical signs are rather important from exam point of view than a clinician point of view so there are a bunch of names and I'm sure the hot seaters here uh just a moment yeah the H seat is here can help in naming some of the signs so one of the commonest signs that you can find in an individual with thyroid disease is there is infrequent blinking and what is it called what is the sign called star sign perfect okay lid retraction in primary gaze darle sign perfect Descent of upper lid in down case um W graph V perfect so this is one of the most important signs I mean w graph is the goto sign okay so it is almost universally present in all individuals with thyroid disease lower Li lagon upcase it's called Griffith sign and deeper injection of the temporal conjunctiva is almost uh universally present again and it is the gold Z sign so all these signs the paralysis of one or more extraocular muscle is called as ballet sign and all these signs can be divided into four categories lip signs muscle signs Globe signs and pupilary signs so like I said most of these signs are important from the exam point of view and hence like I don't I don't think the time would allow us to go through with every sign but then um for all those who have to make a note can just freeze this slide and just write down the names and uh the explanation of each sign so any individual that walks into your clinic with a probable thyroid ey disease is it's very important that there is complete documentation of all symptoms and signs so some of the symptoms that the patients with thyroid ey disease can present is non-specific like excessive lacrimation Sandy sensation like there is a foreign body sensation there can be some discomfort or there can be a deep retrobulbar pain photophobia red eye all these are extremely non-specific some of the specific signs include eyelid retraction so whenever there's an eyelid retraction first thing you would like to think about is the thyroid eye disease puffy ey puffy ey is related to some uh edema around the eyelids bulging eye that is proptosis uh double vision reduced Vision all related to uh extraocular muscle and the optic nerve involvement so uh uh for do mentation one must always check with starting with visual Acuity color vision and pupil so these are indicators of the optic nerve function one must do a thorough examination of the Cora on slit lamp because according to a study about 10% of the thyroid ey disease individuals have positive Coral staining and why does that happen Dr subab or Dr Ru why can there be Coral involvement lead lack and exposure changes at night correct so there can be because of Lids lag lid retraction there can be some exposure but what is also important is thyroid disease uh uh individuals they can have deficient uh teer fil okay so what we don't expect and but what is proven and what is known is that there is a deficient tofilm so there will be some Coral changes which has to be documented then there is always you need to uh measure IOP in three gazes up gaze straight gaze and down gaze why is that why is there IOP changes in thyroid disease um in in upase we might have a rise in the inocular pressure why does that happen yeah it is called intermittent spiking of IOP so why does that happen one is because of possible ocular motility restriction and raised episcleral Venus pressure perfect yeah so that's what happens okay so in different cases there will be motility restriction which causes the pressure on the globe to mount and hence rise of IOP and always optic dis examination must be done because uh uh if you need to knowe changes of hyperemia or disa so uh you must also check uh the eyelid measurements mrd1 mrd2 and entire measurement because this gives you a um a measure of solid retraction you must measure proptosis and it can be done using hurtles or one the EXO thermometers you must check ey motility in all nine cases because during monitoring of the disease with medical management one must see that there is an improvement in the ocular motility lastly soft tissue signs very very important in thyroid ey disease why is soft tissue sign important in thyroid ey disease is because it gives an indicator of disease activity now thyroid ey disease is a typically a basic disease so so there is an active disease and there is an inactive disease so the first step in the management of thyroid ey disease is to establish whether the patient is presenting with an active disease or an inactive disease and hence one needs to consider what is known as a Randle curve so this Rundle scur beautifully described by Dr Rundle uh in one of the Publications way back in 1945 where he described that uh with rise in INF infation within the orbit there is a rise in severity and with the reduction in the activity or the inflammation in the orbit the severity also comes down and it reaches a plateau phase and this deficiency the gap between the activity and the severity that you see is due to probably the uh incomplete uh uh healing of the patient that leads to certain functional deficit so like I said thyroid ey disease activity is one of the most important things that you need to monitor at the time of presentation and this can be done using one of the uh grading system which can be no specs Visa C or uh modification of cast by the ugogo group so wner no specs of ofal mopy index includes six parameters out of which Sorry Seven parameters out of which the first two have no uh uh uh number uh n stands for no clinical signs or symptoms o stands for only signs and no symptoms whereas the next five parameters soft tissue involvement proptosis extraocular muscle involvement Coral involvement and sight loss due to optic nerve involvement can be graded as mild moderate and severe with a maximum score that can come up to 15 Visa activity score by dolman and rootman has four different parameters that is is Vision inflammation strabismus and appearance so you see that this is a very very comprehensive classification which includes various categories various markings various gradings and this is a very useful uh way of uh assessing especially in a patient who has had chronic thyroid disease and is coming to you again and again and you know you need to assess everything in a very systematic fashion but unfortunately in the clinic uh that we see sometimes you know uh this kind of an comprehensive monitoring and recording may not be possible and also what we have is a very simplified and a beautiful uh uh scoring system uh which uh Yogo has given it has four different parameters out of which pain redness and swelling are the three parameters which you must assess at the initial visit only so uh pain that can be pain uh which is spont anous retr BBA which gives a marking of one pain which on I which is there on ey movement again there is a score of one redness of the eyelid which gives a score of plus one as you see in this patient in the first figure there is no redness at all around the eyelid but there is definite redness in the second picture so that that gives a scoring of + one fourth parameter there redness in the conjunctiva which is greater than one quadrant which gives the scoring of plus one this conjunctival redness can be mild moderate or severe as you can judge by these pictures uh swelling can be present in the eyelids which can be again mild moderate and severe the swelling of the eyelid can be described as thickening of the subcutaneous tissue you can see the thickening in the skin here or there can be a proper feston formation as you see in the this picture it can involve one eye it can involve two eyes it can involve one eyelid or it can involve all all four eyelids swelling of the conjuntiva chemosis again plus one scoring and you describe chemosis as a definite chemosis when there is prolapse of the conjunctiva be Beyond The Gray Line so swelling of the Kinkle now even that has a scoring of plus one and swelling of Carle can be described as e the chemosis or hyperemia of just the Kinkle or plus or minus Pica semilunaris so as you see in this second image there is definite chemosis and um hyperemia of the congestion of the semi Pica sem lunaris and the kenle so when a patient is presenting to you for the first time with these symptoms and you do a clinical scoring of plus one for each parameter and the scoring comes greater than three then definitely the disease is active however when a patient comes to you on a second visit and follow off visits there is three other parameters which get added that is worsening of proptosis greater than 2 mm over 3 months or worsening of extraocular movement greater than 5 degree in 3 months or worsening of visual accurity greater than one line over 3 months again plus one scoring for each and when the scoring is greater than a total of four on 10 then definitely the disease is continuing to be active even on fall off visits so Yogo severity measure is where you they have disced the Yogo group the European Graves group on Graves orbitopathy has described the uh Graves disease in three different uh severity measures the first one is s threatening Graves orbitopathy here this can include either D thyroid optic neuropathy or there is a corneal breakdown as you see in this patient there is moderate to severe Graves orbitopathy that is here there is no side threatening graes orbitopathy however it is severe enough to cause impact sufficient impact on daily life which justifies the risk of immunosuppressive treatment mild graze orbitopathy when there is certain signs and symptoms but it does not cause much impact on daily life and it is these signs and symptoms are insufficient to justify immunosuppressive treatment so like I mentioned numerous times pre in this uh lecture that thyroid disease is mainly a clinical diagnosis so you do not require biochemistry that includes T3 T4 TSH and antithyroid antibody measurements for the diagnosis as also you do not require CT or MRI for the diagnosis however Imaging can be necessary and Dr subab or Dr ruu can you please tell me in what situation is Imaging necessary ma'am uh in cases of thyroid disease we would image ideally uh each patient uh whenever we plan on intervening with intravenous methalone to have a baseline record of how the radiological picture looks and also with ocular extraocular muscle measurements perfect okay and also when there is certain uh doubt you know you're not sure whether the thyroid ey disease diagnosis is correct not correct whether you know uh you're looking at any slow Dural arterial fistula you know you want to make sure that this is what you're looking at okay and also when then you are planning an orbital decompression surgery because you want to get an idea of the overall orbital picture how much of expansion there really is whether it is the extra muscles which are mainly involved or whether it is fat expansion and where exactly you want to work in the orbit and also to determine whether there is any optic nerve compression so now tell me would you prefer would you order a CT or an MRI scan which is the preferred modality Dr Ru Dr subba probably MRI for the soft tissue involvement also for the extraocular muscle thickness and for barits index for optic now crowding we would uh prefer MRI over city scan but for planning for decompression uh CT also adds Yeah so basically CT is the most preferred modality because you know because of the presence of fat in the orbit it provides an excellent contrast as it is so you can actually see uh the entire optic nerve and you can also see the extraocular muscle and you can see how much of the orbit is actually expanded so CT is the most preferred modality however uh so what are the typical signs on CT scan um and largement of the belly of the reti with tons correct so as you can see here there is expansion of the bellies of the um medial reti but there is no involvement of the tendon second is an expansion of the intraconal space perfect uh suggestive of and uh then we also correlate that with muscle belly thickening to know whether it is a muscle predominant or fat predominant kind of a thyroid disease perfect okay so yeah so you need to look at both the actual sections and the coronal sections in the actual section of course you can make out the thickening of the belly and no involvement of the tendons in the actual sections as you go from anterior posteriorly you look at the muscle crowding at the posterior uh orbit to see how much of uh volume consumption at near and volume crowding is happening near the optic nerve okay so uh we also need CT scan for uh knowing the barats muscle index and Barett muscle index is basically uh used to determine the D thyroid presence of D thyroid optic neuropathy it is determined by a plus b by c as you can see here uh or D+ e by f as you can see here and when this percentage is greater ler than 67 most likely the patient is likely to have this thyroid optic neuropathy and like I mentioned CT is sufficient in most of the cases however thyroid ey disease also is an ex excellent uh modality to especially determine whether the disease is active or not which is not uh uh you cannot see that in a CT scan of course clinically you can determine whether the patient is active or inactive but over multiple followups with the steroid treatment and other kinds of treatment sometimes the clinically the patient appears to have an inactive disease but on MRI scan when you see the t2 FS T2 fat saturated scans you can see that there is some hyperintense uh you can see here there is hyperintensity streaks within the extraocular muscles which is an indicator of disease activity so you know that there is still some inflammatory activity be going on the extraocular muscles and this may guide your eventual treatment okay so to summarize uh in thyroid ey disease uh patients first of all clinical evaluation is most important it documentation of the signs symptoms and the uh disease activity to uh disease activity can be established using the clinical activity score to establish whether the disease is active because that will help in initiating rescue therapy or the medical treatment which will be dealt with in the next uh lecture series if on uh clinical activity score the disease is inactive then you just follow up the patient over a couple of months and years and uh rehabilitative surgery may or may not be given to such patients thank you thank you so much ma'am for the wonderful session and we thoroughly enjoyed it and u now if you allow I would like to take some questions from the social media definitely ma'am so the first question is how to go ahead with a case uh uh in a case with u thyroid levels like what should we consider as diagnostic so okay so when you talk about a you thyroid patient I'm assuming that this is a patient who has walked into your clinic and who has certain signs of thyroid ey disease that's what I'm ma'am you need to check the presentation again the Pres presentation is not coming so we don't need the presentation you can stop m' I'm sorry I can stop sharing yes ma'am yeah okay so I'm assuming that this youu thyroid patient that we're talking about has certain clinical signs and symptoms and that's why he's walked into the clinic okay say a patient has walked in and has some amount of L retraction and has some discomfort in the eyes so first what you do is uh you uh and you're suspecting that the patient is the case of thyroid dises like I mentioned you uh document the signs and the symptoms and like I said the most important thing is the clinical activity score take all the and since this the first time the patient has walked into your clinic there are seven parameters which are related uh to the pain movement on movement pain on rest and similar those seven parameters and if the parameters are the scoring is greater than three on seven then definitely the patient is has an active thyroid uh uh ey disease okay now in a patient with active thyroid disease it does not matter whether the patient is U thyroid or hyper or or hypothyroid you have to treat the disease as an orbital inflammation okay it's a great thing that the patient is you thyroid all right but if the patient is hypothyroid or hyperthyroid your additional treatment would be to send the patient to an endocrinologist and make sure that you correct the thyroid disorder so that the activity in the orbit is also controlled however the P if the patient is already ID it is a great thing that the patient does not require addition treatment for normalizing thyroid levels okay ma'am ma'am next question we have is uh how to assess clinically assess a case of thyroid disease in a pediotic patient okay so in a pediatric patient it can become quite uh challenging because first of all the patient is non-cooperative and secondly uh it's very rare that you see Hy hypo thyroid disease in a pediatric child so mostly in pediatric cases as we have noted most of the children are hyper or hypothyroid and hardly any youth thyroid pediatric patients present to you okay so they would have already come with the diagnosis of hyper or hypothyroidism and then you assess on a similar note that you know you go with lid retraction whether there is any orbital inflammation any is similarly as you do in adults but of course you may not get accurate values but the fact that the patient is hypo or hyper thyroid will add to your diagnosis and how to ma'am go ahead with imaging do we uh advise the patient to go ahead with CT or MRI straight away on first visit in a pediatric patient you say in a pediatric patient ma'am in a pediatric patient I would say that MRI would be better like I said MRI is more informative as compared to CT and especially in a child this is going to be more important because clinically assessment may not be 100% accurate and Mr SC since it it is safer first of all and secondly it will help you evaluate the disease activity within the extraocular muscles whether there is any inflammation or not so definitely an MRI scan would be preferred in uh a child and yes you would order an MRI scan in the very first visit okay ma'am next question we have is um importance of fundus or disk evaluation in a case of Ted I mean it is I think I've already covered in this lecture series uh any patient that walks into your clinic and you're suspecting thyroid disease there has to be a complete evaluation starting with visual acute and uh intraocular pressure corneal evaluation there should be pupil examination everything and this includes posterior segment evaluation as well like we mentioned there is in thyroid disease due to the actual pathology where there is impaired Venus congestion uh it leads to it may or may not lead to raised IOP however even in the presence of normal IOP sometimes due to the compressive effects of on the globe then may be involvement of the optic nerve and it may cause just hyperemia with or without dis Adema and hence every patient of thyroid disease the evaluation of fundus examination is completely uh valid next question we have is what all things should be kept in mind while evaluating a case of Ted undergoing treatment with ivmp okay so I think this part can actually be covered by Dr haava once he covers the medical management however what I would like to mention here is like orbital uh thyroid ey disease is an orbital inflammatory disease okay and you're working around a very close space where you are uh dealing with the probable congestion uh in the orbit that leads to Optical decompression so that when you know that there is ivmp treatment necessary uh all you need to do is the BP and sugar monitoring at the time of giving ivmp however if when whenever we need to give ivmp there I mean uh an endocrinologist can be definitely become a part of the team and these sugar monitoring can be done but ivmp has to be given at all costs okay ma'am uh how to differentiate a case of Ted from multifocal myositis clinically so like I mention on a CT scan or an M clinically clinically so yeah so clinically uh first of all the pain associated with the myositis is severe it is mostly a very acute disease and uh multifocal myositis you can whenever you ask the patient to do the nine gazes the pain is severe you do not see a similar amount of tenderness and pain in a patient with thyroid disease more there is more of motility restriction than pain in a thyroid disease whereas in myositis pain is more than motility restriction okay and radiologically speaking of course whenever in doubt you go for radiological diagnosis so on a CT or MRI what you can see in multifocal myositis is there is definite tendon involvement whereas in thyroid disas there is no tendon involvement okay and any particular points to be asked during history taking uh to differentiate between Ted and multifocal myositis uh I would say that the chronicity of the condition acute onset that's all because myositis is mostly an acute Subacute condition and thyroid disease the presentation is would be more of Subacute to Chronic uh ma'am how to avoid subjective variations uh in uh like while assessing the case uh assessing the severity of a case uh for sake um clinical activity score and suppose if I measure and someone else measures there is definitive difference between someone may feel like there is a cular congestion and someone might feel that there is no cicular congestion so how to avoid that subjective variation during assessment see unfortunately it cannot be avoided but like like I shown you the images you can definitely use these images in your mental map and then you know you can make sure and whenever see even as you saw in the images that I've showed you when I mentioned there is conjunct there's congestion as a plus one score it is not whether it is is severe or moderate so differentiating between a severe and a moderate case would be difficult but uh conjunct congestion even mild moderate sever is graded as a plus one score okay so what you may call as mild maybe sub can call it moderate okay but either mild or moderate it can be plus it is plus one only okay so there's hardly any I think subjective opinion on whether there is no congestion or yes congestion congestion is congestion it should be seen you know is what I would say even with matter of lid edema like I showed you it can be one eyelid it can be four eyelids it can be one eye two eyes but even in the presence of a little bit of eyelid edema it is a plus one score okay uh the next question we have is how to go ahead with a case of inactive Ted and clinical activity for zero so in activ TV I would say like we mentioned the first step in the management of thyroid disease is to establish whether it is an active disease or inactive disease and inactive disease is cool you don't have to give a medical management at all but in inactive thyroid disease you have to see why has the patient come to you okay is it the proptosis that's bothering him is it the squin that is bothering him or is it the eyelid retraction okay so eyelid retraction is mainly an aesthetic concern a proptosis would be an aesthetic concern also uh but a motility restriction would be the patient is presenting with diplopia okay so based on what these symptoms are what this presentation is in inactive thyroid ey disease you go for rehabilitative surgery after establishing that there is no activity for at least 6 months and what should be the ideal followup in a case of inactive uh TD I would say that every four to six months okay okay and at the same time the patients uh T3 T4 TSH also is repeated every four to 6 months lab investigations you advise to a case of Ted okay again uh underlining the fact that thyroid disease is a clinical disease so biochemical evaluation is is not necessary in all cases however uh in the first uh um uh followup you may want to advise T3 T4 TSH and antithyroid antibodies because these are the modifiable risk factors when a patient is presenting with thyroid ey disease and T3 T4 TSH and antithyroid antibodies they are uh at abnormal levels connecting these uh biochemical U markers can help in control of the orbital disease as well uh ma'am can you please explain in brief about Newen score about Newen score ma'am Newen score I'm sorry I'm not aware of it okay uh can you please explain the reason for uh temporal flare temporal flare is uh yeah so this is mainly because of the IID retraction okay so it is seen that the lateral rectus is mainly involved and the there is congestion over the lateral rectus which is reflected over the uh lat temporal region of the eye as also because of lid retraction it is the temporal part of the globe that is mostly exposed and most of the times it is the temporal FL flare that is visible more than any other part of the globe is there any particular sequence of evolution of lead signs in active Ted no not at all there is no particular sequence no and activity score it includes the lid like I said the clinical signs are just more important from exam point of view not from a clinician point of view and in the clinical activity score the eyelid there are only two parameters that are involved one is whether there is eyelid uh uh H uh edema or not and whether there is IID hyperemia or not okay ma' and of course I retraction which is on followup yeah okay so is there any particular reason to commonly find inferior rectus involvement more frequently uh in the case of Ted yes so you will see this answer in several textbooks an explanation to this when you go back the anatomy of the orbit you see that you the Lev palpalis and Superior oblique muscle and there is medial rectus and inferior rectus however in the inferior part of the orbit that is inferior rectus inferior oblique along with a lot of ligaments okay and the uh orbital structures in the inferior part of the orbit and around the inferior rectus there are so many ligaments that there is more commonly involvement along these and causing which causes inflamation and scarring more commonly around the inferior rectus than anywhere else so the next question we have is uh is there any uh particular reason uh for uh aggravation of a severity of a case of Ted with smoking uh not really no such uh cause has been established it is just which has been studied and seen that smoking aggravates thyroid ey disease but there is no uh proper effect in cause establishment as of now okay ma'am um Dr subba do you have any further questions uh no like lot of uh thank you and gratefulness for for such a wonderful lecture ma'am but I think most of this you guys already knew right I mean there was nothing new probably no no no we got lot of it was uh good to revise everything have everything in a nutshell and to revisit all those uh is signs with a pictographic memory for future references ma'am I had a question from my like uh what are the standardized testing conditions while doing a hurtles exo of like uh you're asking me this not just from thyroid Idis point of view right normally ma'am yeah ma'am in general so okay so basically you know that hurtles EXO themometer it rests on the zygomatic Arch right yeah so you must make sure that the uh the entire scale of the hurtles is resting properly and straight on the zygomatic Arch and there are some people who have had fractures previously and we may not be aware so you must take a quick history whether you know there has been any injury or something because if there is any part of the zymatic arch that may have been injured previously the hurtles just doesn't hold right okay so you place the hurt exha themometer here and then to avoid Parallax of error you sit right in front of the patient and then make sure there is overlapping of the two lines M uh one of the other questions which I had is when whenever we examine a patient say baseline or on followup a case of an active Ted and then on our applanation tonometry by Goldman's tonometer we observe that there are high IOP readings and that he not in any Ana medication what are the factors do we consider like as a novice measuring this IOP for the very first time uh what are the um like physician based factors instrument factors and the patient factors before we directly jump in to start an anti-lock medication for the patient yeah so what we have been doing at Nara Nala is this particular decision of starting anti-lock medication is something that we have stopped taking the decision we directly send them to glaucoma Consultants but what I have noticed is in any patient who has uh raised IOP even in a particular gaze say just up gaze forget down gaze or straight just even in upase they first get a visual Fields done okay so when the IOP is uh raised but visual fields are intact and the patient is the kind who would follow up they do not start Antiga medication immediately they wait for three to four months they wait whether to see whether the effect of our um steroid treatment ibmv treatment has had any effect on the globe motility reduction of IOP they wait for 3 to four months and then do a visual field repeat and see whether Antiga medication has to be started or not okay so this particular decision of starting an and and um anti-a medication it's not with us anymore we have a very comprehensive team and I think that is the right way to go because uh their their experience tells them when exactly it requires to be started but again it wouldn't hurt start Antiga medication on our own in a patient raised IOP for couple of months you know till you know that your uh treatment is going to kick in and the IOP is going to reduce there's no harm in starting Antiga uh for couple of months on the same note ma'am if I were to add addendum to it uh let us say that uh whenever we started the patient on say oral steroid therapy or intravenous methal pron therapy and and then we realize that a patient is a steroid responder then how do we go about this case like just continue our treatment for active TD in conjunction with consultation of the glaucoma specialist yes I've had one patient like that who unfortunately had I mean fortunately had a completely normal IOP before I started uh uh steroid therapy but once I started an ivmp he came within two days saying his eyes are red and it's burning and he's not sleeping well I could not pinpoint what the thing was until I checked his pressure it was elevated he was a steroid responder immediately sent him to the glaucoma department and he was uh started on Antiga medication immediately and mam what could possibly explain the um dry eye disease in a patient with a thyroid active thyroid eye disease is it like uh the lag of tmos or at particularly at night which causes this accentuation of dry or is it an increase in the OA surface area where the lids are unable to cover uh like what possibly explains the the mix of all these factors see for a proper tier film uh we all know for a proper tier film distribution our blinking is very necessary we do about 12 to 15 blings in a minute and it is extremely important so one of the important signs that you see in thyroid ey disease is that there is infrequent blinking okay as also there is lit retraction there can be some amount of lag of thus all these factors leads to a definite increased tier film breakup time okay yes Ma and also last question for uh the postgraduates whenever they are two things one on the theory front and the other on the Practical exam Point uh if this active Ted is given as a long answer question where Poss it is for 10 marks how do you want them to basically channelize is the thoughts in the examination where we have a poity of time and yet everything has to be put on paper one the second set to this is uh in a practical examination when so much has to be done in a worker for a thyroid disease how do they mentally frame that uh probably this uh calculating all the clinical activity score at once and then doing the measurement Parts at once and then putting all together in a very short span of time what advice would you like to give to the postgrad see a theory like a theory is something that I think can be covered in the exact manner as I have described first you go for symptoms documentation of all symptoms documentation of all the signs which we normally do in every patient starting from visual P IOP Coria blah blah and soft tissue sign recording of soft tissue signs okay so however on a practical uh note when a patient is presented to you and you know you have to document everything like it has to be we you just go for the ask for the symptoms and go for the clinical activity score okay forget about doing everything in a proper fashion way but just go for the activity score and you establish whether the disease is active or not so one must go according to the clinical activity score with 10 parameters m' one question I had from my end is uh how to assess a case uh of te after intra LPS steroid injection like is there any particular measurements or is there anything particular we need to see yeah so after intra LPA steroid injection for a couple of weeks you cannot definitely measure the uh lid edema lid hyperemia or the lid retraction part okay for anything it takes about six to eight weeks to settle down once the uh the trauma of you have iatrogenic trauma you having been given the intra um LPS Tri roid has come down that takes about 6 to 8 weeks then you can assess in a very similar fashion there should be no difference in how you would assess such a patient immediately posttop it is difficult to put down all these measurements because they are not valid yeah uh thank you so very much ma'am thank you thank you so much yeah before we conclude for tonight I have a small announcement to make next on the 20th of December for the next lecture thyroid disease the medical management by Dr Santos see you all that see you you thank you so much