CIME 2024: Identifying the constellation of signs and symptoms in TED

From lateral flare to eye morphology, there are several signs and symptoms to look out for in diagnosing thyroid eye disease (TED), according to Kelsey Roelofs, MD. She details practical methods to diagnose the disease in her Controversies in Modern Eye Care 2024 presentation, "TED In Focus: Collaborative Strategies for the Management of Thyroid Eye Disease," presented alongside Daniel B. Rootman, MD, MS; Amy Patel Jain, MD; and Selina McGee, OD, FAAO.

Video Transcript

Editor’s note - The following transcript has been lightly edited for clarity.

Kelsey Roelofs, MD:

Hi my name is Kelsey Roelofs. I'm an oculoplastic surgeon. I'm currently an assistant professor at the University of California, Los Angeles. Today I'll be talking a little bit about thyroid eye disease. Thyroid eye disease is a condition which most commonly affects patients who have Graves hyperthyroidism, but it can happen in other thyroid issues like Hashimotos thyroiditis, as well. And in a small portion of patients with thyroid eye disease, their thyroid labs are actually within the normal limits. So we call this euthyroid TED. Thyroid eye disease presents with a number of different signs and symptoms and there's not really 1 specific test or, you know, diagnostic imaging that we do to diagnose TED. It's based on a constellation of signs and symptoms. So in terms of some of the characteristic or hallmark things that we look for in diagnosing TED, the upper eyelid position can become more retracted with lateral flare. That's very stereotypical of thyroid eye disease. Not many other things will give you upper eyelid retraction and that change in contour. But in some cases, some of the changes in thyroid disease can be more subtle. So 1 of my most practical tips, I would say, when you have someone coming to you think might have thyroid eye disease is to ask to see old photos of them. Because on old photos, you can compare what the patient's initial eye morphology or appearance looked like to what they look like in the chair in front of you. It's a really helpful way to pick up on subtle changes in upper eyelid position or contour, or in bulging or proptosis of the eyes. Because we all start out at a different level. Normal is different for each of us and so old photographs, I think, are very, very helpful. So that's basically an overview of what I'll be talking about today. Early identification of patients who you think might have thyroid eye disease is super important because it can have a really significant negative impact on their quality of life. And so we want to identify those patients as soon as we can so that we can manage them, and in an ideal world optimize their disease course as best as possible.

So I think the important things for the optometrists to know, are 1, if you see someone presenting to your clinic that you think might have thyroid eye disease, but they've not been diagnosed with a thyroid problem, you need to recommend that they see their primary care doctor to have some thyroid blood tests ordered. That's really important because uncontrolled hyperthyroidism can have significant negative consequences for their systemic health. And oftentimes, or in some cases, at least, patients present first with eyes symptoms. So that's number 1, you have someone coming to you with upper eyelid retraction, lateral flare, or proptosis. You want to make sure that they follow up with their primary care doctor. If they have a known thyroid condition that's been managed and you wonder if perhaps now they're developing thyroid eye disease, then referring them or integrating their care with someone who cares for patients, specifically with thyroid eye disease like myself, oculoplastic surgeons in general, I think is really helpful, because it helps to establish that multidisciplinary circle of care around the patient. And there are a lot of evolving treatments for thyroid eye disease. So it's really important to have a multidisciplinary approach from the get-go. And then I think the third thing I would mention is that it's really [important] to monitor for things like dysthyroid optic neuropathy, because these are the situations that thyroid eye disease can cause permanent vision loss and so it's really important not to miss them. And I think the best way to screen for that in your patient you're monitoring with stable TED is with color vision, so Ishihara plates for example, it's a very useful vital in thyroid eye disease.