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Thyroid gland - Thyroid Eye Disease

In This Article

Introduction

Thyroid eye disease (thyroid associated ophthalmopathy)– often accompanies, and is only ever present with Grave’s disease.

  • The Mechanism is not fully understood, but it is thought to be caused by a common antigen shared by ocular and thyroid tissue. As a result, there is an immune response that causes retro-orbital inflammation.
  • There is swelling of the extra-ocular muscles which is caused by fibroblast activation. The fibroblasts are activated by cytokines which have been released by T cells and macrophages. The activation of fibroblasts causes glycosaminoglycan accumulation, which leads to oedema and fibrosis.
  • The retina is also affected.
  • The inability to fully close the eyelid may lead to corneal damage.
  • There is also conjunctival oedema and inflammation.
  • The swelling and oedema of the extra-ocular muscles leads to limitation of movement and proptosis. Proptosis is where the eye protrudes forward out of the orbit. The proptosis is usually bilateral but can be unilateral.
  • Ultimately there will be increased pressure on the optic nerve, which may cause optic atrophy.
  • Although the ocular manifestations are only related to Grave’s disease, they can occur in patients who suffer from the condition but are hypothyroid, euthyroid and hyperthyroid – i.e. the severity of the eye disease is not related to the severity of the thyrotoxicosis.
  • The eye symptoms are more common after treatment with radioiodine than treatment with anti-thyroid drugs.  5-10% of cases of thyroid eye disease threaten the patients sight – however, the discomfort and cosmetic problems, as well as the risk that sight may be affected often causes patients great anxiety. Ophthalmopathy is more common in smokers.
 
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Clinical features

Feature
Assessment
Frequency
Lid lag / lid retracted
Measure lid fissure width
50-60%
Grittyness, discomfort, periorbital oedema, pain, excessive tears.
Self assessment score by patient
40%
Proptosis (aka exophthalmos) this is where the eye bulges out of its socket.
Exopthalmometry or evaluation on MR/CT scan.
20%
Extraocular muscle dysfunction – typically causes diplopia (double vision) when looking up and out.
Hess chart + CT/MR to detect muscle size
10%
Corneal involvement, causing exposure keratitis
Flourescin staining
<5%
Loss of sight due to optic nerve compression
Visual acuity tests, visual field tests. CT/MR scan
<1%
In about 10% of patients, the signs will only be unilateral.
 
 
 
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Treatment

  • Treatment of thyrotoxicosis will not result in improvement of symptoms of thyroid eye disease.
  • Hypothyroidism should be avoided – as this can exacerbate the problem.
  • Stopping smoking may have a large benefit – it may even alleviate the need for further treatment.
  • Eye-drops may be given to improve patient comfort and aid lubrication
  • Sleeping upright – may benefit some patients – as may taping the eyes closed
  • Systemic steroids – can reduce the inflammation if sever symptoms are present.
  • Irradiation of the orbits – can improve eye movement and reduce inflammation, but does not reduce the level of proptosis.
  • Lid surgery – will help protect the cornea if the lids cannot normally be closed
  • Surgical decompression of the orbits o   Corrective eye muscle surgery – is often very good at improving diplopia.

- See more at: http://almostadoctor.co.uk/content/systems/endocrinology/thyroid-gland/thyroid-eye-disease#sthash.GxEY1CjS.dpuf