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Thyroid eye disease

Background knowledge ๐Ÿง 

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.

Aetiology and pathophysiology

  1. Autoimmune response targeting TSH receptor.
  2. Inflammation and swelling of orbital tissues (muscles, fat).
  3. Fibroblast proliferation and glycosaminoglycan deposition.
  4. 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 ๐ŸŒก๏ธ

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 ๐Ÿงช

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 ๐Ÿฅผ

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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