TED Talks: AAO Virtual 2020 provides the latest on thyroid eye disease

During a series of lectures on thyroid eye disease (TED) during the recently-concluded AAO 2020 Virtual conference, Steven M. Couch, MD, presented a to-do list for patients with newly-diagnosed thyroid eye disease. He should know. Dr Couch has been studying the disorder for years and most recently presented new data on the demographic and clinical characteristics of patients with TED. Along with his colleagues, the associate professor of ophthalmology and visual sciences at Washington University School of Medicine in St. Louis conducted a multi-institutional retrospective review to identify patients with TED who had superior isolated or predominant rectus/levator complex involvement. Among their findings at baseline:

• 19 individuals met the criteria, and all showed an enlarged levator/superior rectus complex
• The average clinical activity score was 2.1
• All had proptosis on the affected side
• Lid abnormalities were higher in the affected side
• Six in every 10 patients had vertical misalignment

After an average of 18 months of follow-up:

• The average clinical activity score was 1.3
• ~Half had proptosis
• Vertical misalignment rate was unchanged compared with baseline
• Repeat imaging revealed interval enlargement of the extraocular muscles

Dr Couch’s team concluded that “in the setting of abnormal TSI and/or thyrotropin receptor antibody, presence of upper eyelid retraction, and an otherwise unremarkable laboratory and systemic evaluation, a presumptive diagnosis of TED may be made, and the patient can be followed closely, as he/she is likely to develop involvement of other extraocular muscles, consistent with a more typical presentation of TED.”

Nahyoung Grace Lee, MD, assistant professor of ophthalmology at Harvard Medical School, addressed the audience on the topic of upper eyelid retraction.  She acknowledged the challenge of achieving reliable results, particularly in individuals with TED. Performing best practices is key. Dr Lee drew largely from the key principles that were published earlier this year. They include:

• To attain the desired amount of eyelid lowering, use an external approach through an eyelid crease incision for recession of the levator muscle, levator aponeurosis, and Mueller muscle
• For smaller scale recessions, use an internal approach through the superior palpebral conjunctiva, which provides access to Muller muscle and levator aponeurosis
• You can choose to use sutures or bypass suture use. If you utilize them, you can select either fixed or adjustable sutures

Christina Choe, MD, a private practice oculoplastic surgeon in Hendersonville, NC, offered her expertise on TED masquerades. It has been noted that immunoglobulin G4 -related orbital disease can masquerade as TED, and vice versa. Indeed, the IgG4 subtype is common in TED. Individuals with the subtype and TED tend to be older, have more severe disease, and higher clinical activity scores. Clinicians are advised to be aware that the subtype plays an important role in the pathogenesis of TED.