Abstract
Purpose: :
Expert estimates suggest that 50-85% of patients with Thyroid Eye Disease (TED) are referred for evaluation later than desired. This is felt to reflect poor detection of clinical signs of this condition, such as exophthalmos (EXOPH) which can be masked by concurrent periocular alterations. In addition, most patients at risk for TED are managed by primary care and internal medicine physicians without special tools such as exophthalmometers. We sought to develop a simple method to screen for EXOPH, Lateral Brow Exophthalmometry (LBE) which could be used by most health care providers to detect EXOPH.
Methods: :
Patients: 35 Orbit Service patients in whom we suspected EXOPH were included. Demographic data including: Age, ethnicity and gender were collected. Historic data: previous suspicion of EXOPH, previous TED, orbit fracture, chronic steroid use andother causes of EXOPH were obtained Clinical data: Hertel exophthalmometry, lid position and orbit soft tissue assessment was obtained. Objective EXOPH was defined in 1 of 3 ways: exophthalmometry readings above gender and ethnic norms, showing increase and alteration of eye position documented from prior photographs. LBE: a rounded linear rod, was held vertically, resting on the superior orbital rim in the plane of the corneal apex. LBE was considered positive (+) if the extended line of the posterior rod surface would intersect the cornea and negative if it was anterior to the corneal apex. Photodocumentation for the study was then obtained using standard camera orientation and position. Data analysis: Photographs were printed then coded and examined in a masked fashion for LBE. LBE was correlated with specialist suspicion of EXOPH, objective EXOPH and referring provider suspicion of EXOPH.
Results: :
Patient age ranged from 25-82 years. Ethnicity included Caucasian, African American, Hispanic and Asian patients. The most common diagnosis was TED, though in over 30% of cases, EXOPH was unsuspected. Over 90% of patients with + LBE had objective EXOPH. Over 90% of patients with EXOPH suspected by the specialist showed + LBE. The exceptions included patients with TED and very deep set orbits. Similarly, over 90% of patients whose EXOPH was not suspected by referring providers had + LBE.
Conclusions: :
LBE is an extremely simple and safe method for detecting EXOPH requiring little equipment and training. It is effective both in settings where exophthalmos is very likely as well as when it is unsuspected. This technique should greatly enhance the detection of exophthalmos and appropriate referral of patients.