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Dr. Rajaii:
There are a lot of new exciting treatments in the pipeline for thyroid eye disease, or TED. However, for most of these treatments to be successful, we need to use them early on during the active disease phase.

What are those early symptoms we should watch for? This is CME on ReachMD, and I’m Dr. Fatemeh Rajaii.

Dr. Subramanian: 
And I’m Dr. Prem Subramanian.

I think you hit the nail on the head there regarding this need. Because in the past, when this was more of a surgical disease, early diagnosis wasn’t as critical. But now, that early diagnosis means early intervention that we can use to control the disease and minimize the appearance of those signs and symptoms, the classic signs like eyelid retraction and proptosis.

Now, of course, some of these early symptoms can mimic other conditions that are not TED. Things like chronic dry eye, allergies with redness and itching, or even glaucoma, where the patient may have elevated IOP and even get a little bit of eye redness. So we need to be aware of that. We need to ask our patients always if they smoke because cigarette smoking is a significant risk factor for development of TED and may accelerate early TED. And always asking about comorbid thyroid disease, hyperthyroidism, but even and especially in younger patients, hypothyroidism could be autoimmune and is a red flag. But you can’t rule out TED if thyroid dysfunction is not present if testing is negative. And so there have to be other things that we use.

How do we distinguish TED from other non-TED conditions that we take care of?

Dr. Rajaii:
That’s a great question, Prem. We have to keep in mind that there is mimicry of other orbital conditions such as orbital myositis, idiopathic orbital inflammatory syndrome, or tumors. Imaging features can be helpful. MRI and/or CT would demonstrate any lesions as well as inflammation in the orbit. For TED specifically, we look for inflammation and enlargement of the orbital fat as well as extraocular muscles, which can be distinguished from myositis because it spares the tendons in TED. And then serologic testing such as thyroid function tests and testing for thyroid-stimulating antibodies and other thyroid disease-related antibodies can be helpful.

Dr. Subramanian: 
I couldn’t agree more, and, Fatemeh, you brought up some really great points. And as we wrap up here today, what I want our colleagues to know is that common things are common, right? We see lots of patients with chronic dry eye and glaucoma, but we should always keep TED in mind as a possible diagnosis when our patients aren’t responding to treatment for these common conditions like ocular allergy. And also, when we see a patient with glaucoma who’s on the younger side, has no family history or other identifiable risk factors, or who has more orbital pain than you would normally see with primary open-angle glaucoma, we must look for other signs or symptoms of TED because orbital venous congestion may occur early in this disease and may be missed if it doesn’t cause a red eye or periocular swelling.

I encourage people not to hesitate to consultwith people like you or me in neuro-ophthalmological or oculoplastics to help order additional tests, to investigate, or even to have us see that patient in consultation. You don’t need to label them with TED before sending them to us. Rather, just tell us your suspicious, that you can’t figure out what’s going on, and we can help you to take a closer look or even to start therapy if, indeed, they do have thyroid eye disease.

Dr. Rajaii: 
Great point. And I’ll add just to keep thyroid eye disease on the differential for any adults you see with proptosis, orbital inflammation, or ocular surface inflammatory disease, and to try to remember to include thyroid function tests and thyroid antibody testing as part of the workup for these conditions.

Prem, thank you for joining me today.

Dr. Subramanian: 
Thank you so much.

Dr. Rajaii: 
And to our audience, thank you. This has been CME on ReachMD.

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