Transcript
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Episode 2
Dr. Kossler:
Hello, I'm Dr. Andrea Kossler. Joining me today is Dr. Prem Subramanian, a dear friend and a world expert on thyroid eye disease.
Prem, we've all had those patients that, despite having a low CAS, the patient is miserable and experiencing a significant disease burden. How do these patients typically present in your clinical practice?
Dr. Subramanian:
Andrea, you are right, these patients are a real challenge. We heard a little bit about that from Kim in the previous episode. And so I want to give you an example today of a patient who presented to me.
As you know, I see a lot of patients with thyroid eye disease who might have diplopia, not as much of the outward symptomatology. And this patient in particular was a woman who’s 49 years old. She had recently been diagnosed with Graves’ disease, and she did have some hypertension, hyperlipidemia, typical things that you might see at this age. She didn't smoke. She was taking methimazole to control her hyperthyroidism. And she came to see me because she was starting to have double vision that was interfering with her work as a nail technician because, especially when she looked down, she would start having double vision.
And so on my exam, I did notice she had some prominence of her eyes, not so much proptosis as more eyelid retraction. She definitely had some limitation of elevation of her left eye that then led to some vertical strabismus, and she also had a deficit of depression of her right eye. So all of these things together led to an incomitant strabismus causing her double vision, interfering with her job, and making her really miserable.
But she didn't have red eyes, she didn't have any swelling, she didn't have pain, and really she had a little bit of eye redness. And so this gave her a CAS score of, at best, 2. And so she was sent to me with this idea of, "Oh my gosh, what do we do for this patient, because she doesn't have a high CAS?"
And I'll mention even another type of patient where CAS is low, but the disease burden is high, and that might be in our older patients who are losing vision. They might not even realize it. I saw a patient who was 73. She had had compressive optic neuropathy on the right. She was living in Florida at the time. She was treated there first with steroids and then with an orbital decompression because she did have a high CAS at that time. Everything settled down as far as she was concerned.
She moved to Colorado, came to see me, and I found she now had an RAPD on the other side, on the left side, with decreased vision, decreased color vision. Her fundus looked normal, but when I went ahead and got CT imaging on her, we found that she had apical crowding. You could see the evidence of the prior decompression on the right side, and on the left her apex was very full, and she had compressive optic neuropathy. Her CAS was 0.
And so Kim brought this up before.
The 3 scales that exist to measure disease activity and severity really need to be put into context of what our patients are experiencing. The CAS is great, tells us about inflammation, but even if the patient doesn't have redness, swelling, pain, they may still have significant disability from their disease. The EUGOGO classification captures that in telling us that we need to determine how it is that the disease is affecting our patients and using that as a key element in our determination of mild, moderate to severe, or sight-threatening disease. And then finally we can use the VISA scale in our clinics to track change over time and see if our patients are truly getting better, getting worse, or staying the same.
And so really, as we sit in front of our patients and we try to determine who needs treatment, I think we have to remember that it's the things they are telling us, the problems in their life that are being created by their TED, their diplopia, their loss of vision, their abnormal outward appearance, that we have to keep in mind before we start therapy.
Dr. Kossler:
Your case so nicely demonstrates the limitations of the 7-point CAS tool, and I completely agree with you that we really need to think about what our patient is experiencing and what is progressing.
And I think the VISA score does that nicely. If their vision, their proptosis, their strabismus, and yes, their inflammation is worsening over time, I consider that to be dynamic disease or active disease. And then I would consider treatment. So I really think that this is a nice example of the poor predictive value of the CAS score and how important it is to just consider what the patient is telling you.
It was really nice to hear your thoughts on this. Stay tuned for our next episode, where we're going to talk more about using these tools in our everyday practice.
Thanks for joining. We'll see you next time.
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You’re listening to Evolve Med Ed on ReachMD. This activity is provided by Evolve Medical Education and is part of our MinuteCE curriculum.
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