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David S. Bardenstein; Concurrent Eyelid Malpositions In Thyroid Associated Orbitopathy: A Likely Cause Of Delayed Diagnosis. Invest. Ophthalmol. Vis. Sci. 2011;52(14):5108.
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Thyroid Associated Orbitopathy (TAO) is a very common and grossly underdiagnosed condition. It can cause significant dysfunction including vision loss, intractable diplopia, corneal exposure and ulcer, and grossly distort orbital anatomy. In a significant proportion of cases, diagnosis of both the TAO and underlying thyroid disease depends on detection of the eye disease. In many patients, even when the thyroid abnormality is recognized, the diagnosis is delayed. The diagnosis is dependent upon clinical identification of lid and orbit abnormalities. This is frequently done in one of two ways. Limited exams by care givers not specializing in lid and orbit disease, specialist exams and sub-specialist exams by those focused on lid and orbit disease. Overlooking TAO findings by any of these groups can lead to delayed diagnosis or delayed treatment. In addition, the demographics of TAO overlaps with that of eyelid malposition (ptosis, brow ptosis, ectropion, floppy lids and others) and this study evaluated the concurrent eyelid abnormalities seen in TAO patients.
Patients ( 30) with a history of clinically and laboratory and imaging proved TAO were evaluated clinically with an exam augmented to include detailed evaluation of eyelid malpositions as well as orbital parameters associated with TAO. Specific abnormalities evaluated included brow ptosis, dermatochalasis, ptosis, floppy lids and ectropion. A subjective expert assessment was made regarding whether the lid malpositions were likely or unlikely to obscure the typical findings of TAO. Demographic data including age, gender and ethnic derivation were also collected.
Within the study population the following lid malpositions and periocular soft tissue abnormalities were identified: ptosis, dermatochalasis, brow ptosis, floppy lid syndrome and lower lid ectropion. 7 patients showed no abnormalities and 23 at least one abnormality. 2 abnormalities were seen in 6, 3 seen in 9, 4 seen in 3 and 5 seen in 2 patients respectively. The most common abnormalities were ptosis and dermatochalasis. Diagnoses which could confound the diagnosis were seen in 13 pts. As expected concurrent abnormalities were seen more often with increased age. Both genders were affected.
The results of this study demonstrate that a high percntage of TAO patients have concurrent eyelid abnormalities and a significant proportion of those are abnormalities which could obscure the typical findings of TAO leading to missed or delayed diagnosis.
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