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Dr. Subramanian:
It is not uncommon for patients with thyroid eye disease, or TED, to experience misdiagnosis and diagnostic delays. What should optometrists and ophthalmologists be looking for to make the right diagnosis?

This is CME on ReachMD, and I’m Dr. Prem Subramanian.

Dr. McGee:
Hi. I’m Dr. Selina McGee, and as an optometrist I do see a lot of dry eye patients, and early symptoms of TED can mimic chronic dry eye and other conditions like allergic conjunctivitis. So if we have those patients that come in with dry eye symptoms that are recalcitrant, patients also will complain of itching and redness that can very much look like allergic conjunctivitis. What’s distinguishing about it and is different is, with TED, you don’t have papillae like you would have in allergic conjunctivitis. Patients can also have eye pain. It typically is a deep, boring kind of pain, and then also elevated IOP [intraocular pressure], which can get misdiagnosed as glaucoma. Smoking is a risk factor. Classic signs that we see are eyelid retraction and proptosis, but keep in mind that about 10% of patients with TED have hypothyroidism or normal thyroid function. Antibody testing can certainly be helpful, and then looking at a clinical activity score, or CAS, measures disease severity, and then what our next steps could be and what is needed for treatment.

So as we go through here, Prem, as a specialist, what else do you recommend and look for and suggest to the primary eye care providers to watch out for?

Dr. Subramanian:
Selina, you hit on some important points there about early diagnosis being important to minimize the impact of this disease over time, and you pointed out that looking at things like inflammation may lead us to an early recognition of disease and early treatment in the active phase to minimize the disease severity.

And I think what I would tell my colleagues is that the classic signs of TED, like proptosis or eyelid retraction, may actually occur later on. And so the things that you were pointing out, things like puffiness in the periorbital area, redness, things that may be mistaken for allergy or other conditions, may come well before eyelid retraction is going to occur.

And the co-management of patients is really important in this regard. And what I would suggest is that referring patients to a specialist, like a neuro-ophthalmologist or an oculoplastic specialist, who takes care of these patients, if you’re unsure of the TED diagnosis is quite appropriate because it will help us to look at the differential and see if there might be some other process present. We can establish a baseline, if TED is present, and then work with our colleagues to say, okay, does this patient need additional treatment under our care? Can they be referred back to you to manage at that point? And in addition, as specialists, we have access to more advanced imaging, proper MRI and CT protocols that will help us in finding additional markers of TED that may be helpful in identifying these patients early on. And we really want to watch out for signs of optic neuropathy and exposure keratopathy that could lead to vision loss.

Dr. McGee:
Those are all great points. And as we wrap up here, I would just like to remind my primary colleagues to remember that TED patients need a team of collaborative care around them. So I always think it’s a good idea to already have an established relationship with your endocrinologist, with an oculoplastic surgeon, as well as a neuro-ophthalmologist so that when you have these patients, you can co-manage inside that network with your TED patients.

Dr. Subramanian: 
Selina, that’s great advice. And I would add that chronic eye redness has a wide differential and especially in dry climates like yours and mine here in Colorado, typical ocular surface diseases are very common. But when patients fail to respond appropriately to treatment or they have other signs or symptoms, we should not forget to think about TED even when the patient does not have a history of systemic thyroid disorder or characteristic signs and symptoms like eyelid retraction and proptosis.

So, Selina, again, I want to thank you for joining us.

Dr. McGee: 
Thank you for having me.

Dr. Subramanian: 
And this has been CME on ReachMD. Thank you to our audience for tuning in as well.

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