By Selina R. McGee, OD, FAAO
Sept. 8, 2021
Your patients come to you with a variety of medical eyecare needs, many of which they don’t know until you tell them about it. There is one subgroup of patients, however, who often do know they need your medical eyecare services: those with diseases impacting their thyroid gland, and by extension, their eyes.
Letting doctors in your community know that you treat patients whose eyes are impacted by thyroid conditions helps build your co-management referral network, and educating patients about these services ensures they receive the care they need while adding a new revenue stream to your practice. These patients frequently have struggled with ocular discomfort for a long time, and will be grateful to the doctor who brought them relief. That could result in many new friends and family referrals.
Subset of Patients In Need of Care
I have a handful of patients with thyroid eye disease (TED), and many more with hyperthyroidism and hypothyroidism, typically caused by Graves’ disease and Hashimoto’s disease respectively. TED is considered a standalone disease and can occur even when euthroid is achieved. Up to 50 percent of patients with Graves’ disease will develop TED, 10 percent of patients with TED are euthyroid or hypothyroid.
At the root of this condition’s pathophysiology is the activation of orbital fibroblasts by autoantibodies, which leads to orbital inflammation early on in the disease and subsequent fibrosis. Subsequent ocular pathologies due to orbital inflammation are:
• Dry Eye
• Exposure /Proptosis
• Lid Retraction/Lagophthalmos
• Blink Dynamics/Frictional Forces
• Ocular Inflammation
• Autoimmune Conditions
• Optic Nerve Compression
• Inflammation and fibrosis inside a confined space
• EOM infiltration, Inflammation, and Fibrosis
Optometry has an opportunity and an obligation to identify and treat these patients early in their disease because we many times will be the first line of defense because of the symptoms patients experience.
• Remember early symptoms of TED are as follows:
• 65% DED
• 51% Diplopia
• 32% Blurry Vision
• 13% VF Defects
• 7% Reduced Color Vision
• 6-9% Severe Sight Threatening Optic Neuropathy
Physicians view TED as a self-limiting disease, yet:
• Only 2 percent of patients consider themselves recovered at the end of this “self-limiting” phase
• Often overlooked, or under-acknowledged in treatment, is the chronic ocular discomfort, visual impairment and morbidity rate commonly associated with TED.
• This disease severely impacts patients emotionally and psychologically, which is also too often under-treated.
Co-Manage Patients, Expanding Your Referral Network
I co-manage patients with thyroid conditions primarily with primary care physicians (PCPs), endocrinologists and oculoplastic surgeons. I am working on building a network of ODs, oculoplastics, endocrinology and PCPs, so they know my practice is the best place to send patients whose conditions are impacting their eyes.
Many physicians aren’t aware of what we have to offer as optometrists. It’s our responsibility to help educate and increase awareness as well as access to great care. I reach out to other doctors in my community to introduce myself and educate them about the services my practice provides, including for patients with thyroid conditions.
Educate Patients with Thyroid Disease About Their Eyes & Need for Additional Care
All ODs can create awareness and discuss the symptoms associated with TED, so patients know who to turn to if symptoms arise. There is a new drug available, Tepezza (teprotumimab), that treats TED in the inflammatory stage versus the fibrotic stage, so it’s imperative that these patients are treated early in their disease.
Tepezza is an infusion given at an infusion center eight times every three weeks. Research revealed a signaling pathway that involves activation of insulin-like growth factor 1 receptors (IGF-1R) in patients with Graves’ disease. This pathway acts synergistically with thyroid-stimulating hormone receptors and enhances the mechanism of action, increasing orbital tissue inflammation.
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Tepezza works by blocking the IGF-1R, therefore, the actions of IGF-1 are inhibited and the inflammatory and proliferative process associated with Graves’ ophthalmopathy may be diminished. It’s treating the disease in its inflammatory infancy versus late-stage fibrosis, which is historically how when we treated these patients. We watched and waited. We watched and waited as patients were sometimes devastated by proptosis and subsequent changes to their appearance. We watched to ensure that patients didn’t have possible blindness due to optic nerve compression.
Creating awareness is key because we can greatly impact patients’ lives by treating early with Tepezza. When patients are treated early, invasive surgeries like orbital decompression, and lid surgeries that can be disfiguring, may be completely avoided.
Click HERE for patient education resources that you can use in your exam room conversations with patients, or to refer patients to, so they can learn more, following their office visit.
Little-to-No Instrumentation Investment Needed
The Hertel exophthalmometer is instrumental in measuring proptosis and can be purchased for around $300. Every OD already owns a slit-lamp and visual field, so that will round out all the equipment one would need to serve patients with thyroid conditions impacting their eyes.
Your greatest resource in the care of patients with thyroid conditions is your own expertise and care as an optometrist practicing a high level of medical eyecare. You have the chance to relieve these patients of significant discomfort, improving their quality of life, while educating them about the additional care and medications that may make a huge difference in their lives. In the process, you will build greater relationships with referring physicians and long-lasting, loyal patients likely to refer many others.
Selina R. McGee, OD, FAAO, is the founder of BeSpoke Vision in Oklahoma and is also vice-president of Intrepid Eye Society and past-president Oklahoma Association of Optometric Physicians. To contact her: email@example.com