touchOPHTHALMOLOGY touchOPHTHALMOLOGY
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Tutorial

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Poll

Do you work with or have access to a combined ophthalmologyā€“endocrinology clinic?

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I work in a combined clinic
   
I refer patients to a combined clinic
   
There is no local combined clinic
   
I have no access to a combined clinic
   

Tutorial

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Poll

What is the most common presenting sign of TED in your experience?

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Dry eye symptoms
   
Eyelid retraction
   
Proptosis
   
Diplopia
   

Tutorial

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Poll

Approximately what proportion of your patients with TED have Gravesā€™ disease?

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25%
   
50%
   
75%
   
Nearly all
   
 
Video Take CE/CME Test
Ocular Immunology CE/CME accredited

touchPANEL DISCUSSION
A visually engaging discussion designed to emulate a ā€˜liveā€™ panel experience and provide clinicians with practical expert insights to address their clinical challenges. Useful tips below will show how to navigate the activity. Close

Thyroid eye disease: An evolving continuum of care

  • Select in the video player controls bar to choose subtitle language. Subtitles available in English, Saudi Arabia, French, German, Italian, Japanese, Portuguese, Spanish.
  • Downloads including slides are available for this activity in the Toolkit
Learning Objectives

After watching this activity, participants should be better able to:

  • Understand the pathophysiology of TED and identify those who are most at risk for developing the disease
  • Recognize the signs and symptoms of TED and the burden of disease in affected patients
  • Describe the process for screening and diagnosing TED
Overview

In this activity, three experts provide their perspectives on the mechanisms underlying thyroid eye disease, risk factors, symptomatology and burden of disease in affected patients, as well as the process for screening and diagnosis. The discussion is guided by pre-canvassed questions provided by healthcare professionals involved in the management of patients with thyroid eye disease.

This activity is jointly provided by USF Health and touchIME. read more

Target Audience

This activity has been designed to meet the educational needs of endocrinologists, ENT specialists, ophthalmologists and oculoplastic surgeons (notably trainees/residents), and primary care practitioners involved in the management of patients with thyroid eye disease.

USF Accreditation

Disclosures

USF Health adheres to the Standards for Integrity and Independence in Accredited Continuing Education. All individuals in a position to influence content have disclosed to USF Health any financial relationship with an ineligible organization. USF Health has reviewed and mitigated all relevant financial relationships related to the content of the activity. The relevant relationships are listed below. All individuals not listed have no relevant financial relationships.

Faculty

Dr Andrea Kossler discloses: Consulting fees from Acelyrin, Amgen, Argenx, Genentech, Immunovant, Kriya, Lassen and Viridian. Grants/research support from Amgen, Kriya, Lassen, Sling and Viridian.

Dr Edsel Ing has no financial interests/relationships or affiliations to disclose in relation to this activity.

Dr Mario Salvi discloses: Advisory board/panel fees from Amgen and IBSA. Consulting fees from Aesara, IBSA, Inmagene, Lycia and Tourmaline. Grants/research support from Immunovant, Roche, Sling and Viridian.

Content reviewer

John Steven Jarstad, MD, FAAO, FRSM-UK has no financial interests/relationships or affiliations in relation to this activity.

Touch Medical Contributors

Christina Mackins-Crabtree has no financial interests/relationships or affiliations in relation to this activity.

Rebecca Franklin discloses: Independent contractor relationship with Fishawack Communications (relationship terminated).

USF Health Office of Continuing Professional Development and touchIME staff have no financial interests/relationships or affiliations in relation to this activity.

Requirements for Successful Completion

In order to receive credit for this activity, participants must review the content and complete the post-test and evaluation form. Statements of credit are awarded upon successful completion of the post-test and evaluation form.

If you have questions regarding credit please contact cpdsupport@usf.eduĀ 

Accreditations

Physicians

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through a joint providership of USF Health and touchIME. USF Health is accredited by the ACCME to provide continuing medical education for physicians.

USF Health designates this enduring material for a maximum of 0.75 AMA PRA Category 1Ā CreditTM.Ā  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Advanced Practice Providers

Physician Assistants may claim a maximum of 0.75 Category 1Ā credits for completing this activity. NCCPA accepts AMA PRA Category 1Ā CreditTM from organizations accredited by ACCME or a recognized state medical society.

The AANPCP accepts certificates of participation for educational activities approved for AMA PRA Category 1Ā CreditTM by ACCME-accredited providers. APRNs who participate will receive a certificate of completion commensurate with the extent of their participation.

If you have any questions regarding credit, please contact cpdsupport@usf.edu

EBACĀ® Accreditation

touchIME is an EBACĀ® accredited provider since 2023.

This programme is accredited by the European Board for Accreditation of Continuing Education for Health Professionals (EBACĀ®) for 0.75 hours of effective education time.

The Accreditation Council for Continuing Medical Education (ACCMEĀ®), and the Royal College of Physicians and Surgeons of Canada hold an agreement on mutual recognition on substantive equivalency of accreditation systems with EBACĀ®.

Through an agreement between the European Board for Accreditation of Continuing Education for Health Professionals and the American Medical Association (AMA), physicians may convert EBACĀ® CE creditsĀ to AMA PRA Category 1 CreditsTM. Information on the process to convert EBACĀ® credit to AMA credit can be found on the AMA website. Other healthcare professionals may obtain from the AMA a certificate of having participated in an activity eligible for conversion of credit to AMA PRA Category 1 CreditTM.

Faculty Disclosure Statement / Conflict of Interest Policy

In compliance with EBACĀ® guidelines, all speakers/ chairpersons participating in this programme have disclosed or indicated potential conflicts of interest which might cause a bias in the presentations. The Organizing Committee/Course Director is responsible for ensuring that all potential conflicts of interest relevant to the event have been mitigated and declared to the audience prior to the CME activities.

Requirements for Successful Completion

Certificates of Completion may be awarded upon successful completion of the post-test and evaluation form. If you have completed one hour or more of effective education through EBACĀ® accredited CE activities, please contact us at accreditation@touchime.org to receive your EBACĀ® CE credit certificate. EBACĀ® grants 1 CE credit for every hour of education completed.Ā 

Date of original release: 8 August 2024. Date credits expire: 8 August 2025.

Time to complete: 37Ā minutes

If you have any questions regarding the EBACĀ® credits, please contact accreditation@touchime.org

This activity is CE/CME accredited

To obtain the CE/CME credit(s) from this activity, please complete this post-activity test.

Claim Credit
  • Select in the video player controls bar to choose subtitle language. Subtitles available in English, Saudi Arabia, French, German, Italian, Japanese, Portuguese, Spanish.
  • Downloads including slides are available for this activity in the Toolkit

Topics covered in this activity

Ocular Immunology
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touchPANEL DISCUSSION
Thyroid eye disease: An evolving continuum of care
0.75 CE/CME credit

Question 1/5
Which orbital cells are thought to be central to the pathophysiology of TED, involved in both the early inflammation and subsequent remodelling process?

TED, thyroid eye disease.

Bone marrow-derived fibrocytes infiltrate the orbit, become activated and differentiate into CD34+ fibroblasts. Upon activation by thyroid-stimulating antibodies, IGF-1R antibodies and cytokines, CD34+ fibroblasts can proliferate and further differentiate into adipocytes and myofibroblasts. Activated CD34+ fibroblasts can also induce hyaluronan synthesis, cytokine secretion and subsequent inflammation. This leads to orbital tissue expansion, proptosis, compression of the optic nerve and other characteristic clinical manifestations of TED.

Abbreviations

IGF-1R, insulin-like growth factor-1 receptor; TED, thyroid eye disease.

Reference

Men CJ, et al. Ther Adv Ophthalmol. 2021;13:1ā€“14.

Question 2/5
You have a 53-year-old female patient with Gravesā€™ disease. She received radioiodine therapy at age 34 years, her hyperthyroidism is controlled with methimazole, she is receiving statins and is a smoker. How do you help the patient minimize her risk for developing TED?

TED, thyroid eye disease.

Cigarette smoking is a key modifiable risk factor for developing TED.1,2 Mechanisms by which cigarette smoking negatively impacts TED may include increased oxygen-free radical generation, hypoxia in the orbit, enhanced cytokines synthesis and stimulation of adipogenesis.1 Among patients with Gravesā€™ disease, TED is positively associated with current smoking compared with non-smoking, in a dose-response pattern.3 Patients with TED who smoke have a poorer response to treatments, such as corticosteroids and teprotumumab, compared with non-smokers.2 Smoking cessation should therefore be recommended to all patients with Gravesā€™ disease.4

Abbreviation

TED, thyroid eye disease.

References

  1. Bartalena L, et al. Ophthalmic Plast Reconstr Surg. 2023;39:S2ā€“8.
  2. Miller Oā€™Dell J, et al. Kans J Med. 2023;16:62ā€“4.
  3. Ramesh S, et al. Am J Ophthalmol. 2023;253:74ā€“85.
  4. Coskun M, et al. Endocr Abstr. 2022;83:TO5.
Question 3/5
Which of these statements best summarizes the burden of anxiety and depression among patients with TED?

TED, thyroid eye disease.

Compared with the general population, a high prevalence of anxiety and/or depression has been reported in both patients with active, inflammatory TED and in those with inactive, non-inflammatory TED.1ā€“3 Among patients with TED, pain behind the eyes, photosensitivity, blurred vision and diplopia are more prevalent in those with low QoL scores compared with those with high QoL scores.1 Patients with TED have also reported vision and appearance impairment and psychosocial impact long after acute disease has subsided.1,2

Abbreviations

TED, thyroid eye disease; QoL, quality of life.

References

  1. Cockerham KP, et al. Ophthalmol Ther. 2021;10:975ā€“87.
  2. Wang Y, et al. Endocr Pract. 2022;28:842ā€“46.
  3. Lee TC, et al. Ophthalmic Plast Reconstr Surg. 2023;39:281ā€“87.
Question 4/5
Your patient is at high risk for developing TED and asks what the early signs might be. Which of the following signs would you include in your advice?

TED, thyroid eye disease.

The early signs of TED can be subtle and easily missed.1 Diplopia (double vision) is one of many early diagnostic signs of TED,1 occurring at presentation in around 6ā€“18% of cases.2 During active TED, diplopia may fluctuate, with worsening in the morning.2

Abbreviation

TED, thyroid eye disease.

References

  1. TEDct. 2023. Available at: https://tedct.org.uk/news/early-diagnostic-signs-of-thyroid-eye-disease/ (accessed 11 July 2024).
  2. Shah SS, Patel BC. Thyroid Eye Disease. Updated 2023. Available at: www.ncbi.nlm.nih.gov/books/NBK582134/ (accessed 11 July 2024).
Question 5/5
You are an ophthalmologist. A 62-year-old female with controlled Gravesā€™ disease is referred to you from their endocrinologist with suspected TED. They presented with sudden onset of pain, unilateral proptosis, orbital edema and decreased vision. What differential diagnosis would you consider for this patient?

IgG4, immunoglobulin G4; TED, thyroid eye disease.

Orbital inflammatory syndrome (also known as nonspecific orbital inflammation, orbital inflammatory pseudotumor and idiopathic orbital inflammation) is typically characterized by the abrupt onset of pain, proptosis and other orbital inflammatory signs such as swelling and erythema, which can be similar to TED. Unilateral presentation is more typical but bilateral presentations occur. The most common orbital processes that present with similar clinical pictures as orbital inflammatory syndrome are TED and orbital cellulitis. Differentiating findings for TED that are not features of orbital inflammatory syndrome include lid retraction, lid lag, optic neuropathy and ocular motility restriction. Laboratory tests showing elevated thyroxine and triiodothyronine, decreased thyroid-stimulating hormone and the presence of stimulating autoantibodies would also indicate TED.

Abbreviation

TED, thyroid eye disease.

Reference

American Academy of Ophthalmology. 2024. Available at: https://eyewiki.aao.org/Nonspecific

_Orbital_Inflammation_(Idiopathic_Orbital_Inflammation,_Orbital_Inflammatory_Syndrome,_Orbital_Pseudotumor) (accessed 11 July 2024).

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