【医学ppt课件】Graves′ orbitopathy.ppt

Case report: Graves’ Disease A 43-year-old woman presented with fatigue and reported a weight loss of 22.5 kg (50 lb) during the previous 18 months. P.E. : diaphoresis, cachexia, a resting HR 110 beats/min, and a diffusely enlarged, nontender thyroid gland; lid retraction, mild proptosis,and conjunctival injection. The pt had been aware of a mass growing in the anterior neck for the previous 6 years and recent hair loss, heat intolerance, and a resting tremor. Thyrotropin levels were suppressed, at 0.01 mIU/L (reference range, 0.49 to 4.67). Total levels of triiodothyronine and thyroxine were elevated, at 791 ng/dL (reference range, 79 to 149) and more than 24 μg/dL (reference range, 4.5 to 12), respectively. The results of an immunoassay for levels of unbound triiodothyronine and thyroxine were not available. Dx: Graves’ disease. Tx: propranolol and methimazole resulted in a substantial improvement in fatigue, tremulousness, and tachycardia within 1 week. She was thereafter lost to follow-up. Graves orbitopathy (GO) No sign Only sign: lid retraction, lid lag, staring Soft tissue sign: chemosis, congested conj. Proptosis Extraocular myopathy Corneal epithelial defects (Corneal Ulcer) Sight (Optic neuropathy) American Thyroid Association 1977 藥物治療 大部分的甲狀腺眼疾會自癒，但時間平均為一至二年。因此多數病患在診斷甲狀腺眼疾後只需依病變病情定期追蹤，並依照臨床情形作症狀性治療，例如： (1) 輕度 - 乾眼症：給予人工淚液、人工淚膏、淚管填塞。 - 眼瞼閉合不全：夜間或睡眠時塗抹人工淚膏、或眼瞼黏貼。 - 眼皮水腫：避免過多水分攝取、睡眠時墊高枕頭減少水分聚積。 - 複視：遮眼、佩戴稜鏡、口服降發炎藥物以減少眼外肌水腫。 - 其它：減少抽煙或戒煙。 (2) 中度及重度 - 眼窩放射線照射：但可能產生白內障、網膜、或視神經病變…等併發症。 - 壓迫性視神經病變：可考慮高劑量類固醇注射、或其他免疫抑制劑治療。 手術治療 約5%的甲狀腺眼疾病患須接受手術治療，而手術的時機的選擇非常重要。除非病患處於急性發炎期合併視神經壓迫症狀、或嚴重曝露性角膜潰瘍，必須考慮作緊急眼窩減壓或眼瞼縫合手術；其餘大多數病患應於甲狀腺功能及眼窩發炎控制穩定後，再進行外觀的矯正手術，且手術的進行必需是階段性的。 A wait-and-see strategy in which pts are monitored until symptoms worsen can be challenged. First, many pts with even mild GO have a substantial decrease in their quality of life, as assessed either by general health–related quality-of-life questionnaires or by a GO–specific quality-of-life qu