Discussion begins 1040hrs

THYROID EYE DISEASE Questions:

2/3 Rule

- clinical signs, radiographic signs, lab findings

- Dr Kazim stepwise tests

Dr Cockerham

- opts for all tests at once as some false negative anyway

- eg if hair loss, patient is hypothyroid even if T4 normal now

Dr Dolman

- here we have TSH antibody

Role of OCT

- useful tool in TED

- VF, OCT, HRT, external photos, quality of life survey

Question by Dr SH Lee on how to deal with patient with unilateral TED; if patient very demanding with one eye protruding

- time invested on first visit very important per Dr Kazim

- don't fuss with them surgically in acute phase as discussed

- however, if STABLE unilateral disease, will the other eye become involved?

--> 50% will have 2nd eye involved in first year; the others...quite variable

- Dr C totally agrees, unilateral proptosis more disfiguring. Also, although no solid proof of this, impression that decompression in one eye can trigger disease in other eye

Dr Dolman: TED is self-limiting disorder with inflammatory disorder and while the fire is burning, you don't start your reconstruction. Also, remember the house will have damage from the fire and may never be the same even after reconstruction.

Dr C like to get psychologists involved too if needed

Dr Proctor Q: Is there a role for other immunosuppressive agents in treating TED aside from corticosteroids?

- vast majority of patients will do well if you do nothing so sometimes hesitant to try other agents on these patients; in the future, we will probably have other agents to use but await results of therapeutic trial

Dr D Anderson Q: points out that area of single binocular vision on a VF good tool to show patients their stability

PSEUDOTUMOR CEREBRI Questions:

If Diamox works, when to stop?

- wait til discs no longer swollen

Dr D Anderson: agrees that most patients who come in bad, end up bad. What evidence do you have that steroids help in acute phase?

- Dr C: admits this is anecdotal but no other options; basically to prime them for impending O.R.

No proof of steroids being part of standard of care but no one should go blind in neuro-ophthy without a trial of steroids

Diamox sequels not readily available anymore.

Consider spinal cord tumors in patients and Tb as well if proteins is CSF.

How do you treat patient if has venous thrombosis?

- these patients need surgery; debate whether evacuate or Tx clot

- Tony Arnold puts patients on anticoagulants but not aggressive with TPA or other invasive surgery; do of course Tx the pressure.

- if going down the tube visually and have thrombosis, do have to go on to surgery.