Thyroid Eye Disease — MCQs
What is the most common cause of intermittent proptosis in adults?
Which of the following is the most useful investigation for thyroid function?
Preoperative medication of thyrotoxicosis are all except?
Which of the following is the MOST characteristic feature of thyroid ophthalmopathy?
All of the following are false about eye lid signs in GRAVES DISEASE except?
Most common ocular movement affected in thyroid ophthalmopathy:
Under the WHO "Vision 2020" program, the "SAFE" strategy is adopted for which of the following diseases:
Bilateral ptosis is seen in all except which of the following?
The most common cause of proptosis in adults:-
Which of the following conditions is least likely to cause proptosis?
Thyroid Eye Disease Indian Medical PG Practice Questions and MCQs
Question 1: What is the most common cause of intermittent proptosis in adults?
- A. Orbital varix (Correct Answer)
- B. Thyroid ophthalmopathy
- C. Neuroblastoma
- D. Retinoblastoma
Explanation: ***Orbital varix*** - An **orbital varix** is essentially a varicose vein within the orbit, which can cause intermittent proptosis. - Proptosis in an orbital varix is often exacerbated by activities that increase venous pressure, such as **Valsalva maneuvers**, crying, or bending over. *Thyroid ophthalmopathy* - This condition is characterized by **persistent proptosis**, lid retraction, and ophthalmoplegia, rather than intermittent symptoms. - While it can cause proptosis, it typically presents as **constant and progressive** rather than intermittent proptosis that varies with head position or straining. *Neuroblastoma* - This is a **malignant tumor** that primarily affects infants and young children, not typically adults. - Orbital metastasis from neuroblastoma would cause **progressive, constant proptosis** rather than intermittent proptosis. *Retinoblastoma* - **Retinoblastoma** is a malignant tumor of the retina that primarily affects young children, typically under the age of 5. - While it can cause proptosis in advanced stages, it presents as **constant and progressive proptosis** due to tumor growth, not intermittent proptosis.
Question 2: Which of the following is the most useful investigation for thyroid function?
- A. TSH (Correct Answer)
- B. T3
- C. T4
- D. Thyroglobulin
Explanation: TSH - **Thyroid-Stimulating Hormone (TSH)** is the most sensitive and specific test for assessing thyroid function as it reflects the feedback loop between the pituitary gland and the thyroid [1]. - An abnormal TSH level usually indicates either **hypothyroidism** (high TSH) or **hyperthyroidism** (low TSH), even before changes in T3 or T4 are apparent [1]. *T3* - **Triiodothyronine (T3)** is primarily used to confirm a diagnosis of hyperthyroidism, especially when T4 levels are normal but TSH is suppressed [1]. - It is less reliable for initial screening due to its **short half-life** and significant diurnal variation. [1] *T4* - **Thyroxine (T4)** is a good indicator of thyroid hormone production, but its levels can be affected by **protein binding** and non-thyroidal illnesses. - While total T4 is often included in a thyroid panel, **free T4** is more accurate as it reflects the metabolically active hormone not bound to proteins [1]. *Thyroglobulin* - **Thyroglobulin** is primarily used as a tumor marker for monitoring recurrence in patients with differentiated thyroid cancer after thyroidectomy [1]. - It plays no significant role in the initial **assessment of general thyroid function** or diagnosis of hyper/hypothyroidism [1].
Question 3: Preoperative medication of thyrotoxicosis are all except?
- A. Carbimazole
- B. PTU
- C. Propranolol
- D. Levothyroxine (Correct Answer)
Explanation: Levothyroxine - Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism, meaning it increases thyroid hormone levels, which would worsen thyrotoxicosis [1]. - Its administration would be contraindicated in a patient with thyrotoxicosis, as the goal is to reduce thyroid hormone levels preoperatively. Carbimazole - Carbimazole is a thionamide drug that inhibits the synthesis of thyroid hormones, making it a critical medication for treating hyperthyroidism and preparing patients for surgery [1]. - It reduces the amount of thyroid hormone produced by the thyroid gland, thus mitigating the risks associated with thyrotoxicosis during surgery. PTU - Propylthiouracil (PTU), like carbimazole, is a thionamide that blocks thyroid hormone synthesis and also inhibits the conversion of T4 to T3 [1]. - It is used in the preoperative management of thyrotoxicosis to achieve a euthyroid state and prevent a thyroid storm. Propranolol - Propranolol is a beta-blocker used to manage the symptoms of thyrotoxicosis, particularly the cardiovascular effects such as tachycardia, palpitations, and tremors [1]. - While it does not affect thyroid hormone levels directly, it helps control symptoms and stabilize the patient preoperatively, making them a safer candidate for surgery [1].
Question 4: Which of the following is the MOST characteristic feature of thyroid ophthalmopathy?
- A. External ophthalmoplegia
- B. Proptosis (Correct Answer)
- C. Large extraocular muscle
- D. Lid lag
Explanation: ***Proptosis*** - **Proptosis** (exophthalmos), or anterior bulging of the eyes, is the **hallmark and most characteristic clinical sign** of **thyroid ophthalmopathy** (Graves' ophthalmopathy). - Results from inflammation, edema, and expansion of retro-orbital tissues, particularly extraocular muscles and orbital fat. - **Bilateral proptosis** is the defining feature that distinguishes thyroid eye disease from other orbital conditions. - Present in approximately **60-70% of patients** with Graves' disease and is often the presenting complaint. *External ophthalmoplegia* - **Restrictive myopathy** affecting extraocular muscles is common in thyroid ophthalmopathy, leading to diplopia and limited eye movements. - However, this represents a **secondary manifestation** due to muscle enlargement and fibrosis rather than the primary characteristic feature. - Most commonly affects inferior and medial recti muscles. *Large extraocular muscle* - **Enlargement of extraocular muscles** is indeed characteristic on imaging (CT/MRI) in thyroid ophthalmopathy. - Typically shows **muscle belly enlargement with tendon sparing** (unlike myositis where tendons are involved). - While this is a defining imaging finding, **proptosis remains the primary clinical characteristic** that is most recognizable and diagnostically significant. *Lid lag* - **Lid lag** (von Graefe's sign) is a common clinical sign where the upper eyelid lags behind the eyeball during downward gaze. - Results from sympathetic overactivity and increased Müller's muscle tone in hyperthyroidism. - While frequently present, it is **less specific** than proptosis and can occur in other hyperthyroid states without significant ophthalmopathy.
Question 5: All of the following are false about eye lid signs in GRAVES DISEASE except?
- A. Stellwag's sign: Incomplete and infrequent blinking (Correct Answer)
- B. Mobius sign: convergence insufficiency
- C. Dalrymple sign: lid retraction
- D. Von Graefe's sign: lid lag on downgaze
Explanation: **⚠️ QUESTION ISSUE: All four options are TRUE statements about Graves' disease, making this question technically flawed.** ***Stellwag's sign: Incomplete and infrequent blinking*** ✓ - **Stellwag's sign** is correctly defined as **incomplete and infrequent blinking**, causing a characteristic staring appearance. - This is a **TRUE** sign of **Graves' ophthalmopathy** due to sympathetic overactivity. - **Marked as correct answer**, but all options are actually true. *Mobius sign: convergence insufficiency* ✓ - **Moebius sign** is correctly defined as **convergence insufficiency** (inability to converge eyes for near vision). - This is a **TRUE** sign of **Graves' disease**. - Statement is medically accurate. *Dalrymple sign: lid retraction* ✓ - **Dalrymple's sign** is correctly defined as **lid retraction** (upper eyelid retraction exposing sclera above iris). - This is a **TRUE** and classic sign of **Graves' ophthalmopathy**. - Statement is medically accurate. *Von Graefe's sign: lid lag on downgaze* ✓ - **Von Graefe's sign** is correctly defined as **lid lag on downgaze** (upper eyelid lags behind eyeball during downward gaze). - This is a **TRUE** sign of **Graves' disease**. - Statement is medically accurate. **Educational Note:** This FMGE-2017 question is problematic because all four eyelid sign descriptions are medically accurate. In the actual exam, Stellwag's sign was likely considered the "best" answer, possibly because it's the most specific or commonly tested.
Question 6: Most common ocular movement affected in thyroid ophthalmopathy:
- A. Elevation (Correct Answer)
- B. Adduction
- C. Abduction
- D. Depression
Explanation: ***Elevation*** - **Restrictive myopathy** of the **inferior rectus muscle** is the most common cause of impaired eye elevation in thyroid ophthalmopathy. - This typically leads to **diplopia** on upward gaze, known as **Graves' ophthalmopathy**. - The inferior rectus is the **most frequently affected** muscle, followed by medial rectus, superior rectus, and lateral rectus (mnemonic: "I'M SLow"). *Adduction* - Impaired adduction (inward movement) is less common and usually associated with **medial rectus restriction**. - While it can occur (second most common muscle involvement), it is not the most frequent manifestation of thyroid ophthalmopathy. *Abduction* - Impaired abduction (outward movement) suggests **lateral rectus involvement**, which is the least common in thyroid ophthalmopathy. - **Sixth nerve palsy** would also cause impaired abduction but is not typically directly caused by thyroid ophthalmopathy. *Depression* - Impaired depression (downward movement) is uncommon in thyroid ophthalmopathy. - Depression is primarily controlled by the **inferior rectus** (which is commonly affected but causes elevation problems, not depression problems) and inferior oblique. - Superior rectus involvement would cause impaired elevation, not depression.
Question 7: Under the WHO "Vision 2020" program, the "SAFE" strategy is adopted for which of the following diseases:
- A. Glaucoma
- B. Onchocerciasis
- C. Trachoma (Correct Answer)
- D. Diabetic retinopathy
Explanation: ***Trachoma*** * The SAFE strategy is an acronym for **Surgery** for trichiasis, **Antibiotics** to treat infection (especially azithromycin), **Facial cleanliness**, and **Environmental improvement** to prevent transmission. * This comprehensive approach is central to the global elimination efforts for **trachoma**, as outlined by the WHO's Vision 2020 initiative. *Glaucoma* * Glaucoma management typically involves **medications (eye drops)** to lower intraocular pressure, laser therapy, or **surgery** to improve fluid drainage from the eye. * The SAFE strategy with its specific components (Surgery for trichiasis, Antibiotics, Facial cleanliness, Environmental improvement) is not applicable to the pathophysiology or treatment of **glaucoma**. *Onchocerciasis* * Onchocerciasis, or **river blindness**, is primarily controlled through mass drug administration of **ivermectin** to kill microfilariae and prevent new infections. * While both are Neglected Tropical Diseases causing blindness, the SAFE strategy is not designed for **onchocerciasis** prevention or treatment, which focuses on vector control and anthelmintic drugs. *Diabetic retinopathy* * Management of diabetic retinopathy focuses on **strict glycemic control**, managing blood pressure and lipids, and interventions such as **laser photocoagulation**, intravitreal injections of anti-VEGF agents, or vitrectomy for severe cases. * The term "SAFE strategy" with its specific interventions relates to bacterial infection control and environmental hygiene, which are not primary methods for managing **diabetic retinopathy**.
Question 8: Bilateral ptosis is seen in all except which of the following?
- A. Trauma
- B. Hyperthyroidism (Graves' disease) (Correct Answer)
- C. Congenital
- D. Myotonic dystrophy
Explanation: ***Hyperthyroidism (Graves' disease)*** - **Hyperthyroidism** causes eyelid retraction, leading to a **stare** or **lid lag**, rather than **ptosis**. - **Graves' ophthalmopathy** can cause proptosis (bulging eyes) and conjunctival injection, but does not typically manifest as ptosis. *Congenital* - **Congenital ptosis** is often present at birth due to improper development of the **levator palpebrae superioris muscle**. - It can be **bilateral** and is usually isolated, without other systemic symptoms. *Trauma* - **Traumatic ptosis** can occur if the **levator muscle**, **aponeurosis**, or **third cranial nerve** is damaged. - This can be **bilateral** depending on the nature and extent of the head trauma. *Myotonic dystrophy* - **Myotonic dystrophy** is a **hereditary muscle disorder** characterized by progressive muscle weakness. - **Bilateral ptosis** is a very common early sign of **myotonic dystrophy**, often accompanied by **facial weakness** and **myotonia**.
Question 9: The most common cause of proptosis in adults:-
- A. Preseptal cellulitis
- B. Capillary hemangioma
- C. Thyroid eye disease (Correct Answer)
- D. Orbital cellulitis
Explanation: ***Thyroid eye disease*** - **Thyroid eye disease (TED)**, also known as Graves' ophthalmopathy, is the most common cause of **proptosis** in adults. - It results from an autoimmune process leading to inflammation and expansion of the **extraocular muscles** and orbital fat, which pushes the eyeball forward. *Preseptal cellulitis* - **Preseptal cellulitis** is an infection of the eyelid and periorbital tissue anterior to the orbital septum, typically presenting with **eyelid swelling** and redness. - While it causes periorbital swelling, it generally does not cause true **proptosis**, which is the anterior displacement of the eyeball itself. *Capillary hemangioma* - **Capillary hemangiomas** are benign vascular tumors and are the most common orbital tumor in **infancy and childhood**, not adults. - They typically cause proptosis in young children, often presenting as a **reddish-blue mass** that may increase in size with crying. *Orbital cellulitis* - **Orbital cellulitis** is a serious infection of the tissues within the orbit, posterior to the orbital septum, which can cause **proptosis**, pain, and ophthalmoplegia. - While it is a cause of proptosis, it is an **acute infectious process** and not the most common overall cause of proptosis in the adult population compared to thyroid eye disease.
Question 10: Which of the following conditions is least likely to cause proptosis?
- A. Sarcoidosis
- B. Myxoedema (Correct Answer)
- C. Grave's disease
- D. Pituitary adenoma
Explanation: ***Myxoedema*** - **Myxoedema** is associated with severe **hypothyroidism** and is characterized by non-pitting edema due to the accumulation of **glycosaminoglycans** in tissues. - While it can cause facial puffiness, it is **least likely** to cause **proptosis** as there is no direct mechanism for an increase in orbital contents to push the eye forward. *Grave's disease* - **Grave's disease** is the most common cause of **proptosis** due to **immune-mediated inflammation** and accumulation of **glycosaminoglycans** and fat in the orbital tissues, leading to expansion. - This condition specifically affects the **extraocular muscles** and fat, causing bulging of the eyes. *Sarcoidosis* - **Orbital sarcoidosis** can cause **proptosis** due to the formation of **granulomas** within the orbit, leading to mass effect and inflammation. - It can affect any part of the eye and orbit, leading to varied clinical presentations including axial or non-axial globe displacement. *Pituitary adenoma* - A **pituitary adenoma** itself does not directly cause proptosis as it is located in the **sella turcica**, posterior to the orbits. - However, **large adenomas** can cause proptosis indirectly if they invade the **cavernous sinus** and obstruct venous return from the orbit, or if they are associated with **acromegaly**, which can lead to bony overgrowth of the orbital structures and surrounding tissues.
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