Screening for Graves’ Orbitopathy in Endocrinology Clinic: A multi-disciplinary perspective

Ishani Barai, Parizad Avari, Vickie Lee, Wing-May Kong, Central Middlesex Hospital.

Background: Graves’ hyperthyroidism occurs before or is concomitant with the diagnosis of Graves’ Orbitopathy (GO) in 80% of patients. In practice, detection of GO is often based mostly on clinical examination instead of patient symptomatology. We investigate whether relevant assessment is made in endocrinology clinics to identify Graves’ patients with clinically active GO and whether subsequent referral to ophthalmology is made for further assessment.

Method: A retrospective cohort review of electronic clinic letters of patients seen in endocrinology clinic at a North-West London District General Hospital over a 5-month period from February to June 2018. Patients with thyrotoxicosis were identified and reviewed for use of ‘Vancouver Orbitopathy Rule’ (VOR), a validated screening questionnaire for screening (sensitivity=0.76, specificity=0.82) of GO based on patient symptomatology. The letters were assessed for subsequent GO management from clinic including provisions of an early warning card, artificial tears (lubricant eye drops) or advising on selenium. 

Results: A total of 229 consultations were reviewed of which 32% (n=74) of consultations (mean age 49years, female: 80%, male: 20%) were identified with thyrotoxicosis, excluding those with multi-nodular goitre. One-fifth (20%) had documented VOR questionnaire asked and approximately a quarter (22%) of these were referred to Ophthalmology. Of the new thyrotoxicosis patients (n=9), over half (55%) had documented VOR questionnaire whilst this was lower at 20% with the follow up patients. None were provided with an early warning card, artificial tears for GO or advised on selenium. Smoking status, which is a known risk factor, was documented in 46% of all cases. 

Conclusion: Findings indicate that the VOR questionnaire is being documented for new patients but under-utilised with the follow up patients in endocrinology clinics. However, VOR questionnaire may have employed during the consultation but not documented in the electronic clinic letters.  Greater emphasis is required on providing patients with early warning cards, artificial tears and selenium, in keeping with the latest TEAMed-5 guidance on thyroid eye disease.