Graves’ Ophthalmopathy (Thyroid Eye Disease)

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What is Graves’ Ophthalmopathy (Thyroid Eye Disease)?

Graves’ ophthalmopathy (GO) is a thyroid eye disease (or thyroid-associated ophthalmopathy) that can affect both vision and physical features. Another name for this ocular condition is Graves’ orbitopathy

GO is common among people who have Graves’ disease (approximately 25% to 50%). Graves’ disease is a condition where the thyroid gland is overly active (hyperthyroidism). The thyroid is responsible for regulating the rate of metabolism in the body. 

GO can vary in severity. However, specific symptoms and physical traits characterize this disease, including:

  • Bulging of the eyeballs
  • Dry, gritty ocular sensation
  • Photophobia (light sensitivity)
  • Excessive tearing
  • Double vision (diplopia)
  • The feeling of pressure behind the eye

If a person with GO does not receive proper care, there is an increased risk of temporary or permanent vision loss. 

Finally, although Graves’ orbitopathy can resolve within 1 to 2 years of onset, studies have shown a significant, negative impact on quality of life, mental health, and socioeconomic status. 

You can find Graves’ disease throughout the world. The overall prevalence of the disease is 0.5% worldwide, affecting primarily women in their 30s to 50s.

What Does Thyroid Eye Disease Look Like?

This particular ocular disease will have standard clinical features, including:

  • Upper eyelid retraction
  • Edema (swelling) of tissues in and around the eye
  • Erythema (redness caused by increased blood flow) of the periorbital tissue and conjunctivae (mucous membrane lining the inner eyelid surface and exposed eyeball surface).
  • Proptosis (abnormal protrusion of the eye from the eye socket) 

What Causes Graves’ Ophthalmopathy?

In many cases, Graves’ disease is responsible for the development of Graves’ ophthalmopathy. Graves’ disease is an autoimmune disease in which the body overproduces thyroid hormones, and the immune system responds negatively. 

Because thyroid hormones play a vital role in various body systems, the disease severity of Graves’ ophthalmopathy can differ significantly. 

Additionally, Hashimoto’s thyroiditis may result in Graves’ ophthalmopathy. This disease, also known as chronic lymphocytic thyroiditis, is the most frequent cause of hypothyroidism in the United States. 

The 2009 Amsterdam Declaration signed by more than 80 organizations suggested that incidence and morbidity (disease suffering) caused by Graves’ ophthalmopathy could go down significantly via preventive measures. 

These steps included identifying early warning signs, stopping smoking, facilitating earlier access to specialist care, and avoiding hypothyroidism after radioactive iodine administration. 

Symptoms of Graves’ Ophthalmopathy

If you have this eye condition, you may experience one or more of the listed symptoms below:

  • Dry, itchy, irritated eyes
  • Bug-eyed look due to bulging eyes
  • Light sensitivity
  • Teary eyes
  • The sensation of pain or pressure around the eyes
  • Trouble closing the eyes completely
  • Double vision, especially when during peripheral fields of vision
  • Pain when you move your eyes either up and down or left to right

What Eye Problems Can Graves' Disease Cause?

Graves’ disease is a serious health condition. In many cases, people with this disease can develop Graves’ ophthalmopathy. 

When this occurs, various eye problems can appear. For example, you may develop the following:

  • Caruncular edema (swelling of the small, pink, and globular nodule located in the inner corner of the eye)
  • Chemosis (swelling of the conjunctiva)
  • Conjunctival redness (the thin, transparent lining that covers the inner eyelid and outer surface of the eye)
  • Eyelid redness
  • Eyelid swelling
  • Retrobulbar pain (behind the eyeball)
  • Dysthyroid optic neuropathy (optic nerve dysfunction that could lead to permanent loss of vision)
  • Corneal breakdown or corneal erosion (when the epithelial cells in the cornea begin to break free from the area and cause pain)
  • Exophthalmos (otherwise known as proptosis or displacement of the eye)
  • Diplopia (double vision)
  • Motility restriction
  • Strabismus (improper alignment of the eyes that affects binocular vision)

However, it is important to remember that many of these eye problems are manageable with medications and treatments.

Who is at Risk of Developing Graves’ Ophthalmopathy?

People who have Graves’ disease face a high risk of developing this ocular condition. Almost all cases of Graves’ ophthalmopathy will have Graves’ disease as the underlying health problem. 

Similarly, people with hyperthyroidism (a thyroid hormone problem) or those receiving radioactive iodine treatment may be at risk.

Finally, cigarette smoking (i.e., the number of cigarettes smoked daily) increases the risk of developing a severe form of this disease. Compared to non-smokers, smokers are less likely to respond well to immunosuppressive treatments given to manage the condition. 

Investigators have established an association between smoking and other autoimmune diseases, such as rheumatoid arthritis and Crohn's disease. This observation suggests that smoking may cause a generalized stimulation of autoimmune processes. 

How is Graves’ Disease Diagnosed? 

If you believe you have Graves’ disease, you should seek medical attention. Healthcare professionals can assess your case based on your symptoms and findings during a physical examination. Approximately one out of every three people with the condition will show signs of Graves’ ophthalmopathy. 

To diagnose the disease, doctors may perform one or multiple blood tests. They may also check for an enlarged thyroid and ask about a family history of thyroid or autoimmune problems. 

If clinical doubts remain, doctors may follow up with further blood tests or perform imaging scans like magnetic resonance imaging (MRI). These imaging tests may use small yet safe doses of radioactive iodine to see iodine uptake by the thyroid. 

How to Treat Graves’ Eye Disease

If you have this condition, treatments are available. However, treatment plans will depend on disease severity and individual cases. 

Your doctor may prescribe the use of corticosteroid medication, immunosuppressants, radiation therapy, thyroid surgery, or eye surgery. To provide pain relief from symptoms, your doctor may also recommend medicated eye drops and non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, naproxen, or ibuprofen. 

Finally, if you develop Graves’ orbitopathy, your doctor may prescribe glucocorticoids (steroid medication) as first-line treatment. However, this medication does have strong side effects.  

Also, the novel drug teprotumumab may be an option considered by your eye care specialist. This medication could manage the ocular condition. 

Clinicians may recommend simple yet effective medical management strategies, including smoking cessation or selenium supplement use, to decrease disease severity. 

Graves’ Ophthalmopathy: Common Questions & Answers

How can I check my thyroid at home?

If you want to check your thyroid at home, you’ll need to have a mirror and glass of water at your disposal. Once you have both, take the mirror and hold it in front of you. Focus on the lower, front zone of the next. 

Your thyroid gland will be there, above the collar bone and below the voice box. Tipping your head back while maintaining your focus, drink some water. 

Next, look at your neck as you swallow and see if any bulges or protrusions appear in the swallowing area. 

You’ll want to repeat this process various times, making sure to remember that the gland is closer to the collarbone. If you notice any bulges or protrusions, you should see your healthcare provider for a follow-up confirmation. 

Does thyroid eye disease go back to normal?

Thyroid eye disease can resolve within 1-2 years. However, people with this condition may not always restore their normal orbital anatomy (more than 60% of cases). In these cases, skilled orbital surgery is necessary. 

Can thyroid eye disease resolve on its own?

Yes, it can. It lasts approximately 1-2 years. However, you should speak with your physician to explore management and treatment options. 

Thyroid eye disease is a serious condition that can affect daily life vision dramatically. You may need medications to reduce symptoms and close-up monitoring. 

What is the best treatment for Graves’ disease?

Your doctor may recommend three treatment options, including medications, radioiodine therapy, and thyroid surgery.

In the United States, radioiodine therapy is the most common treatment for this condition. However, treatment plans will vary based on age, pregnancy status, comorbidities, and more.

Does Graves’ disease shorten your life?

Graves’ disease is not life-threatening in most cases. However, if you do not receive care for the condition, you may develop heart problems and weak, delicate bones.

Resources
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Bahn, Rebecca S. “Graves' Ophthalmopathy.The New England Journal of Medicine, U.S. National Library of Medicine, 25 Feb. 2010.

Graves' Disease Rarely Life-Threatening But Can Lead to Heart Problems, Weak Bones.” Mayo Clinic, Mayo Foundation for Medical Education and Research.

Graves' Disease.National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Department of Health and Human Services.

How to Check Your Thyroid.How to Check Your Thyroid | American Association of Clinical Endocrinology.

Hyperthyroidism: Graves' Ophthalmopathy.Hyperthyroidism: Graves' Ophthalmopathy | Michigan Medicine.

Taylor, Peter, et al. “New Insights into the Pathogenesis and Nonsurgical Management of Graves Orbitopathy.Nature News, Nature Publishing Group, 30 Dec. 2019. 

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