Definition

Graves' disease is an autoimmune disorder that attacks the thyroid gland, leading to an increased production of thyroid hormones. Graves' disease has various symptoms, including involvement of the eyes and surrounding tissues. Ophthalmopathy, in this context, can be understood as a disease affecting the eyes. The incidence rate of Graves' ophthalmopathy is estimated to be around 16 cases per 100,000 individuals in women and 2.9 cases per 100,000 individuals in men.

Causes

In Graves' disease, the immune system primarily produces Thyroid-Stimulating Immunoglobulins (TSI) antibodies, which attack the thyroid gland, leading to excessive production of thyroid hormones. The cause of Graves' ophthalmopathy is the immune system also attacking tissues such as fat and muscles behind the eyeball, therefore causing inflammation and swelling. This swelling then pushes the eyeball forward, resulting in a protruding or bulging appearance.

Risk Factor

The risk factors for Graves' ophthalmopathy are associated with the risk factors for Graves' disease itself. While Graves' disease can affect anyone, it is more commonly found in women. Additionally, Graves' disease is typically diagnosed in individuals under the age of 40. However, the risk of Graves' ophthalmopathy is higher in individuals who smoke. Smoking can influence the severity of Graves' ophthalmopathy, and smokers often require additional surgeries to manage the condition.

Symptoms

The symptoms of Graves' ophthalmopathy typically begin to appear about 6 months after the diagnosis of Graves' disease. In some individuals with Graves' ophthalmopathy, symptoms related to excessive thyroid hormone production, such as a racing sensation, increased pulse rate, weight loss, and excessive sweating, may not be felt because hyperthyroidism itself might not occur. The severity of Graves' disease is not necessarily proportional to the symptoms of Graves' ophthalmopathy.

Symptoms that may be observed in Graves' ophthalmopathy include discomfort in the eyes, redness, especially in the white part of the eyes, excessive watery and dry eyes, swelling of the eyelids, double vision, and sensitivity to light. Other noticeable symptoms for both the patient and those around them may include bulging and protrusion of the eyes. In more severe cases, complaints such as difficulty moving the eyeballs and eyelids may arise, and the eyes may not be able to close completely. Additionally, swelling of the tissue behind the eyeball can press on the optic nerve, potentially leading to blindness, although this is rare.

Diagnosis

Diagnosis of Graves' ophthalmopathy begins with the previous diagnosis of Graves' disease. In Graves' disease, the doctor will conduct blood tests to examine thyroid hormone levels and check for the presence of TSI antibodies that cause Graves' disease. If both test results show elevated levels, the diagnosis of Graves' disease can be confirmed.

If you already know that you have Graves' disease and subsequently experience eye disturbances, the doctor can diagnose Graves' ophthalmopathy based on your complaints and a direct eye examination. Eye examinations may include visual acuity, visual field, and eye movement assessments. You may also be asked to close your eyes to see if the eyelids can close completely.

The doctor may also refer you for imaging tests such as CT scans or MRI to assess the position of the eyeballs and the surrounding tissues. From these tests, the doctor can determine whether the tissues behind the eyeballs are swollen, indicative of Graves' ophthalmopathy.

Management

Management of Graves' ophthalmopathy typically begins with managing Graves' disease itself. Medications may be prescribed to reduce TSI antibody levels, such as steroids. Additionally, medications to reduce thyroid hormone levels may be prescribed. If these medications are not effective, the doctor may perform radiation therapy to destroy the tissues behind the eyeballs. This therapy involves exposing the tissues to high-energy X-rays.

Surgery may also be considered to alleviate pressure on the optic nerve, correct the alignment of eye muscles, and ensure the eyelids can close properly. Decompression eye surgery reduces pressure on the optic nerve by cutting bones inside the eye socket and sinuses, providing space for swollen tissues to return the eyes to a normal position. Correction of eye muscle alignment is done if you experience double vision, which is caused by varying lengths of eye muscles. This surgery involves cutting the overly long muscle and attaching it further back. Eyelid surgery can be performed to lengthen the eyelids. This surgery can be done as a preventive measure against complications or as a management of the symptoms themselves.

In Graves' ophthalmopathy, the eyes are prone to dryness due to their protruded position, and the eyelids may not close completely. Therefore, artificial tears may be prescribed for use up to 6 times a day to ensure that your eyes stay moist. This is necessary to prevent infection and injury to the front part of the eyeball, as the eyelids and tears act as natural protectors for the eyes.

Self-care measures include the use of sunglasses. In Graves' ophthalmopathy, your eyes are more sensitive to sunlight and vulnerable to ultraviolet rays. Moreover, if your eyes are too protruded, foreign objects carried by the wind are more likely to injure your eyes. Therefore, wearing sunglasses can protect you from excessively bright light and foreign objects.

Complication

Complications of Graves' ophthalmopathy are the basis for undergoing surgery. In Graves' ophthalmopathy, the protruded position of the eyes can make them more susceptible to dryness and exposure to foreign objects. Complications associated with this include dry eye syndrome, causing discomfort in the eyes. Additionally, if the eyelids cannot close completely, the eyes may become dry. Dry eyes are highly susceptible to scratches, leading to corneal abrasions (a clear layer covering the front of the eye) that can disrupt vision.

If the swelling of tissues compresses eye muscles or if the eye muscles themselves experience severe swelling, complications may involve difficulty in moving the eyeballs and double vision. Moreover, swelling can compress the optic nerve, potentially leading to blindness.

Prevention

Generally, Graves' disease cannot be prevented. However, the risk of Graves' ophthalmopathy can be reduced by avoiding smoking. Additionally, preventive measures can be taken to avoid complications in the eyes. Wearing sunglasses can help prevent complications related to the eye surface. Meanwhile, surgery can be performed to preserve vision function.

When to See a Doctor?

See a doctor promptly if you experience symptoms such as:

• Anxiety and irritability
• Unexplained trembling of hands
• Sensitivity to heat and excessive sweating
• Weight loss despite normal eating patterns
• Lump in the neck
• Changes in menstrual cycles in women, erectile dysfunction in men
• Excessive bowel movements, which can include diarrhoea
• Protruding and bulging eyes
• Fatigue
• Rapid or irregular heartbeat
• Sleep disturbances

These symptoms may indicate that you might have Graves' disease and are at risk of developing Graves' ophthalmopathy. If you are already aware of having Graves' disease, it's advisable to see a doctor promptly if you experience sensations of foreign bodies in the eyes, double vision, or even blindness.

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