#KYJ- Exophthalmos

#KYJ- Exophthalmos

Kelly, a third year nursing student writes: “Rob, my mum has had a throat infection resulting in an inflamed overactive thyroid, and as a result, developed bulging eyes... can you explain the link between thyroid and eyes?

Today’s #knowingYourJargon  word of the day is Exophthalmos.

Say it... “Ex-opf-thal-moss”

This is the noticeable bulging eyes seen in 30-40% of patients with Graves Disease or Autoimmune hyperthyroidism.

In this condition, the thyroid becomes inflamed and hyper-secretes Thyroid hormones.

Patients become tachycardic, hypertensive, hyperthermic and hyperactive.  When it occurs over weeks to months, there is frequently sleeping disturbance, and quite profound weight loss.   Thyroxine up-regulates metabolism and fat burning.   When inflamed, the thyroid can over secrete, causing all these Red Bull like hyped metabolic effects.  There is often an enlarged thyroid on palpating, or inspection.   This swollen football like throat swelling is noticeable and called a Goitre.

Fluid and Sodium shifts also occur causing the interstitial tissues behind the eyes to become profoundly oedematous, pushing the person’s eyes out in a bulging characteristic symptom.  

This is called Exophthalmos , and sadly, is usually a permanent legacy of a long term untreated thyroid over-secretion.

The common initial treatment follows when clinical symptoms (goitre, throat tenderness and tachycardia leading to Atrial Fibrillation) manifest, serum TSH, T3 and T4 levels (Thyroid Function Tests (TFTs)) and Ultrasound to scan the thyroid looking for cancer, nodules and any other thyroid abnormality, are performed.

Thyroid destruction drugs like Carbimazole are usually first line when an acute thyrotoxic storm occurs.  In these emergency situations, the inflamed thyroid gland releases T3, and T4 (Thyroxine) which causes hyper metabolic effects.  Occasionally hypertensive crisis, and AF can occur.   Symptomatic treatment and cardiac protection with beta blockers or Calcium channel blockers is common.

After treatment or surgery to remove the thyroid, the patient will be reliant on daily Thyroxine supplements.

Many of your patients are on Thyroxine for one of two reasons.

Hypothyroidism which is usually age related degeneration.

A bit like post menopausal HRT.

And then there is the hyperthyroid (Graves Disease) patients, who had too much Thyroxine, it was stopped with surgery or Carbimazole, now they are permanently living in the hypothyroid state, and need supplemental Thyroxine.

As nurses you should know that not all brands are the same.  They must be stored differently.

Eltroxin is not the same formula as Oroxine and Eutroxsig. Oroxine and Eutroxsig 

Must be refrigerated right up to administration.

Taken first thing in the morning immediately after waking, on an empty stomach, with a glass of water only- Then Wait at least 30 – 60 minutes after taking the dose before breakfast.  

Other medications, vitamins/minerals herbal medicines and supplements should not be taken at the same time , and the Australian Thyroid Foundation mandates an interval of at least  4 hours after taking Oroxine/Eutroxsig before taking other medications.

Storage of Oroxine and Eutroxsig

It is essential to refrigerate blister strips not yet in use of Oroxine and Eutroxsig between 2 – 8 Degrees Celcius (refrigerated temperature).  Recommendation is to keep all the script of tablets in the refrigerator, all of the time and retrieve the daily dose immediately before administration. It is rapidly destroyed at room temp.

Storage of Eltroxin

Eltroxin does not need to be refrigerated.  Eltroxin should be kept at room temperature below 25 degrees celsius.   Please note Eltroxin is not the same formula as Oroxine/Eutroxsig.  They can not be used interchangeably.

Remember Cold tablets, empty stomach,  no other drugs for 2-4 hours post.  Damn near impossible to achieve given the state of polypharmacy we deal with.