The Curbsiders' 'Hot Takes'

Lid Lag or 'Sand in My Eyes' -- What Could They Mean?

Matthew F. Watto, MD; Paul N. Williams, MD


September 09, 2020

This transcript has been edited for clarity.

Matthew F. Watto, MD: Welcome back to The Curbsiders. I'm Dr Matthew Watto, here with my great friend, Dr Paul Williams. Paul, can you tell us about today's video?

Paul N. Williams, MD: Thanks so much for asking I'm also thrilled to hear that I'm now a great friend. I feel we're getting closer with each video, so we'll be married soon, and I'm looking forward to it. I couldn't do better. Tonight we had the opportunity to talk with Dr Eve Bloomgarden about hyperthyroidism.

Watto: We covered every aspect of diagnosis, treatment, and complications that we could. We are going to start off by giving you three pearls that we thought were really great from this episode. Paul, I'll let you go first.

Williams: We took a delightful detour and ended up talking about Graves orbitopathy (not a word I've ever said before tonight), otherwise known as thyroid-associated eye disease. She talked about the pathophysiology behind each type, which I thought was fascinating. With hyperthyroidism — or thyrotoxicosis, more properly — the patient can have a thyroidal stare or, classically, a lid lag. You ask the patient to look down, and if you see sclera, that's abnormal. It's positive for lid lag. Those are both adrenergic features of thyrotoxicosis, as opposed to Graves orbitopathy, where you have a little bit of proptosis, or the patient may say they have some itchiness, almost like a sand-like sensation in their eye. Those patients should be referred fairly promptly to ophthalmology.

Differentiating the pathophysiology behind each of those things was super-interesting.

Watto: And Graves orbitopathy is caused by thyroid-stimulating immunoglobulins (TSI), as opposed to just the thyroid hormone levels being high. I had no idea that it can occur even if the thyroid hormone levels have normalized.

Williams: Right, because it's not thyroid hormone mediated; it's antibody mediated.

Watto: Speaking of Graves, the main treatment is methimazole. My question to Dr Bloomgarden was, why do patients have such poor adherence to it? Part of that was my own misunderstanding. I thought patients had to be on methimazole for the rest of their lives, but she said she follows the TSI level. When those levels drop off, you can taper the patient off methimazole. They might have recurrence, but some patients don't need to be on it for the rest of their lives.

She sees patients monthly until their levels have normalized, and she is constantly teaching them that they have to take the methimazole, and this is why. That's what you have to do to get people to stay on it. For some reason I've seen people have trouble adhering to this therapy.

Williams: That's a great point. The assumption is that patients are on methimazole in perpetuity, but some patients can actually come off of it. If you explain that at the outset, you might have better adherence.

Dr Bloomgarden has a whole set of rules and regulations that patients must adhere to when taking methimazole. One thing we have to be mindful of is agranulocytosis (which to me has been purely theoretical because I haven't encountered it yet), a potential side effect of the medication. Any time that a patient on methimazole has symptoms of pharyngitis, a sore throat, or a fever — and it sounds like there is some urgency to it — she tells the patient to go to the lab and get a complete blood count, and to call endocrinology while they are on the way to the lab. If it turns out that the patient has agranulocytosis, that's an indication for hospital admission. It's a drastic and severe consequence that needs to be taken very seriously, and I don't think I appreciated that before.

Watto: That's why, even as a primary care or generalist physician, you can start these medications and you probably should have these folks followed by an endocrinologist. They are going to help decide whether the patient needs a thyroid ablation or thyroidectomy.

This is a huge topic. We delved into so many great things with our guest, Dr Eve Bloomgarden. If this sounds interesting to you, you can click on the link below to hear our full conversation.

Click to hear the full episode Thyroid on Fire: Hyperthyroidism with Dr Eve Bloomgarden, or find The Curbsiders' podcasts on iTunes.

The Curbsiders is a national network of students, residents, and clinician educators from across the country, representing 15 different institutions. They "curbside" experts to deconstruct various topics in the world of medicine to provide listeners with clinical pearls, practice-changing knowledge, and bad puns. Learn more about their contributors and follow them on Twitter.

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