Optic Neuropathy Of Graves Disease

    • Slowly progressive monocular or binocular visual loss caused by compression of the optic nerve by swollen extraocular muscles
    • Patient may be euthyroid, hyperthyroid, or hypothyroid
    • Treatment is aimed at reducing compression of the optic nerves
    • Surgical orbital wall decompression may halt or reverse vision loss
    • Corticosteroids provide short-term benefit
    • Teprotumumab, an inhibitor of the insulin-like growth factor 1 receptor, is showing promise in providing preventive benefit
    • Orbital radiation may be effective in non-candidates for surgical orbital wall removal
    • Core clinical features
      • Slowly worsening visual acuity and visual field
      • Nerve fiber bundle defects
      • Soft tissue abnormalities of Graves disease
        • Reduced eye movements
        • Tip: the degree of reduced eye movements is correlated with optic neuropathy
        • Resistance to retropulsion of the eye
        • Lid retraction and lid lag
        • Congested lids and conjunctiva
      • Optic discs appear normal, elevated, or pale
      • Current or past hyperthyroidism or hypothyroidism, but current thyroid function is often normal
      • Thyroid autoantibodies are often present
    • Imaging features
      • Swollen extraocular muscles on axial view
      • Lack of clearance of the optic nerve at the orbital apex on coronal view
    • Optic neuritis
    • Infiltrative (neoplastic) optic neuropathy
    • Compressive optic neuropathy
    • Tip: congestive features and ductional deficits of Graves disease give this diagnosis away!
    • Recommend surgical orbital (especially medial) wall decompression if
      • Visual dysfunction is attributable to optic neuropathy
      • No other cause for optic neuropathy
      • Imaging shows apical orbital compression of the optic nerves by swollen extraocular muscles
      • Trap: surgical decompression will not benefit this type of optic neuropathy unless imaging shows orbital apical compression
    • Prescribe systemic or intraorbital corticosteroid treatment for interim benefit
    • Prescribe orbital radiation if the patient cannot undergo surgery or if surgery is ineffective
    • Visual recovery depends on the degree of pre-existing visual dysfunction
    • Surgical orbital wall decompression may provide stabilization or improvement in visual function, but only if wall removal relieves apical compression
    • Role of teprotumumab, an inhibitor of the insulin-like growth factor 1 receptor, in preventing optic neuropathy is promising but experience is limited
    • Tip: surgical orbital wall decompression may create or worsen diplopia

    Optic Nerve And Chiasm Disorders

    Drusen Optic Neuropathy Colobomatous Optic Neuropathy Optic Pit Neuropathy Morning Glory Optic Neuropathy Hypoplastic Optic Neuropathy Typical Optic Neuritis Atypical Optic Neuritis Papillitis (Neuroretinitis) Non-arteritic Ischemic Optic Neuropathy Arteritic Ischemic Optic Neuropathy Posterior Ischemic Optic Neuropathy Hypotensive Ischemic Optic Neuropathy Radiation-induced Optic Neuropathy Diabetic Papillopathy Hypertensive Optic Disc Edema Papilledema Idiopathic Intracranial Hypertension (Pseudotumor Cerebri) Compressive Optic Neuropathy: Overview Optic Neuropathy of Graves Disease Optic Nerve Sheath Meningioma Sphenoid Meningioma Craniopharyngioma Pituitary Adenoma Pilocytic Astrocytoma (Optic Glioma) Carotid Aneurysm Suprasellar Germinoma Infiltrative (Neoplastic) Optic Neuropathy Paraneoplastic Optic Neuropathy Traumatic Optic Neuropathy Toxic Optic Neuropathy Nutritional Deficiency Optic Neuropathy Dominantly-Inherited Optic Neuropathy Leber Hereditary Optic Neuropathy Primary Open Angle Glaucoma