Thyroid eye disease

Medicine > Endocrine & metabolic

Background knowledge 🧠

Definition

Thyroid eye disease (TED), also known as Graves’ orbitopathy or Graves’ ophthalmopathy.
Autoimmune inflammatory disorder affecting the orbit around the eye.
Associated with thyroid dysfunction, primarily hyperthyroidism.

Epidemiology

Prevalence: Approximately 16/100,000 per year in the UK.
More common in women (5:1 female to male ratio).
Peak incidence: 40-60 years of age.
Smoking increases the risk by 7-8 times.

Pathophysiology

Autoimmune response targeting TSH receptor.
Inflammation and swelling of orbital tissues (muscles, fat).
Fibroblast proliferation and glycosaminoglycan deposition.
Increased intraorbital pressure leading to proptosis and optic nerve compression.

Types

Active (inflammatory phase): Symptoms are more pronounced, lasting 6-24 months.
Inactive (fibrotic phase): Symptoms stabilise or improve but some residual changes may persist.

Clinical Features 🌡️

Symptoms

Gritty sensation in the eyes.
Excessive tearing or dry eyes.
Photophobia.
Double vision (diplopia).
Painful eye movements.

Signs

Proptosis (bulging eyes).
Lid retraction and lag.
Conjunctival redness.
Swelling around the eyes (periorbital oedema).
Restricted eye movements.
Exposure keratopathy.

Investigations 🧪

Tests

Thyroid function tests (TFTs): TSH, Free T4, Free T3.
TSH receptor antibodies (TRAb).
Imaging: Orbital MRI or CT to assess muscle enlargement and optic nerve compression.
Visual field testing if optic neuropathy is suspected.

Management 🥼

Management

To relieve/control severity of symptoms: Smoking cessation, topical lubricants, selenium supplements (100 mcg twice daily).
Radiotherapy for moderate-to-severe cases.
Steroids for severe active disease (oral or intravenous).
Surgical intervention (orbital decompression, strabismus surgery) for optic neuropathy or cosmetic reasons.
Refer to ophthalmologist and endocrinologist for co-management.

Complications

Optic neuropathy.
Corneal ulceration.
Permanent vision loss.
Disfigurement.

Prognosis

Majority improve with treatment.
Some residual effects may persist.
Severe cases may have long-term sequelae.
Regular follow-up required.

Key points

Early diagnosis and intervention are crucial.
Multidisciplinary approach involving ophthalmologists and endocrinologists.
Regular monitoring and adjustment of treatment.
Patient education on disease course and management.

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