GRAVES

OPHTHALMOPATHY

Referred to as :

Graves Disease
Thyroid Orbitopathy
Thyroid Eye Disease (TED)
Thyroid Associated Ophthalmopathy
(TAO)

What is it ?
Graves Disease is an autoimmune disease,
which involves both orbital tissues and the
thyroid gland.
Produce a variety of oculoplastic problems
ranging from periocular swelling to blindness
caused by optic nerve compression

Who gets Graves

Ophthalmopathy ?
Eye problems are most commonly
associated with Graves Disease ( up to
50% of patients may have signs if
examined carefully )
In rare cases it can affect patients with
thyroid carcinoma
Women are much more commonly affected
then men

What causes Graves

Ophthalmopathy ?
Complex and not fully understood
Occurs about 12 -18 month after
the development of
hyperthyroidsm
Can affect people with
Euthyroid or Hypothyroid

Antibodies like those active against

the thyroid damage the soft tissues
in the orbit ( the bony socket of the
eye )

producing inflammation with

enlargement of the muscle and the fat
around the eye

Factors that affect the development

Graves Ophthalmopathy

1. Heredity ( 30% have a family

history )
2. Stress
3. Smoking
4. Environment

Signs and Symptoms

Non infiltrative Ophthalmopathy

- widening of the palpebral fissure

- lag of the globe on upward gaze, or
- lag of the upper lid on downward gaze

cause the eyes to appear exophthalmic,

but there is no proptosis

 Infiltrative Ophthalmopathy
- Edema of the palpebra contents
- Protrusion of the globe
- Infiltration of the extraocular muscle
- Damage to the optic nerve and the
retina
- Increased IOP

Classification of the Ocular Changes

in Graves Disease

Many problems from Graves

Ophthalmopathy
Lid retraction ( upper lid
too high or lower lid too
low )
Double vision
Bulgy eyes
Swelling of the eyelids and
eyeballs
Blurry vision or loss of
vision
Trouble closing the eyelids
and dryness of the eyes /
watering of the eyes

The photo show a patients with marked

upper lid retraction and bulging of the eyes

Bulging red eyes in thyroid eye disease

of

23 y/o woman
presents with the
chief complaint
nervousness.
She has a one
month
history of
increased

nervousness
associated
with a short temper, crying
easily, and tremor. In addition she states she
has lost 25 pounds
without dieting, and is always hot. Her eyes

Pathology
Involves histologic abnormalities in
orbital tissue including :
- extraocular muscles
- orbital fat
- lacrimal glands ,and

- interstitial connective tissue

Extraocular muscle
from a patients with
graves disease and
infiltrative
ophthalmopathy

Edematous orbital fat

and cellular infiltrate

Lacrimal gland
with
mononuclear
infltrate,
fibrosis and an
increase in
ground
substance

End stage in severe involvement of

extraocular muscles in ophthalmopathy

What tests are performed in

patients with Graves
Ophthalmopathy ?
-

Re-check of thyroid function

VA
Assessment of eyelid position and function
Slit lamp exam. of the surface the eye
Pupil testing ( a test of optic nerve
function )
Test of IOP
Color vision testing
Eye movement assessment
CT or MRI of orbits ( to look at the tissue
around the eyes )
Ultrasound scan of the eye muscles

Enlarged muscle on the left side

compared to the right on an MRI scan

Clinical Activity Score

( CAS )
( Table 1 )

To assess treatment of active

inflammatory ophthalmopathy
To predict therapeutic outcome
To select patient for surgical or non
surgical treatment

Table 1. Proposed classification System to assess

Disease activity in Graves ophthalmopathy
Pain
Painfull, oppresive feeling on or behind the globe
Pain on attempted up, side, or down gaze
Redness
Redness of the eyelids
Diffuse redness of the conjunctiva
Swelling
Chemosis
Edema of the eyelids
Increase proptosis of 2 mm or more during a period between 1 and 3
Months
Impaired function
Decrease in VA OF 1 or more lines on the Snellen Chart during a period
between 1 and 3 months
Decrease of the eye movements in any durection equal to or more 5
degrees during a period of time between 1 and 3 months

One point is given for each sign present.

The sum of these points defines the
activity
Score.

Treatment
Depends on the severity of signs and
symptoms
Acute episodes of inflammation result in
double vision and optic nerve compression
recommend HIGH DOSE-ORAL
STEROIDS
( PREDNISON )

Radiation therapy !!! radiation retinopathy

Surgical procedures :
- orbital decompression ( to decrease
proptosis )
- strabismus surgery ( to realign the eyes )
repair of double vision
- lowering of the upper eyelids
- raising the lower eyelids, and
- blepharoplasty
3 to 5 years after onset