Understanding Graves' Disease: Causes, Symptoms, and Treatment

What is Graves' ophthalmopathy?

Graves' ophthalmopathy (GO) is a potentially sight-threatening eye disease associated with thyroid eye disease. Among patients with thyroid eye disease, 90% of them have Graves hyperthyroidism.

What causes patients to develop Graves' ophthalmopathy?

Graves' ophthalmopathy (GO) is an autoimmune eye disease, and genetics play a huge role. People with HLA-DR3, HLA-B8, genes for CTLA4 and TSH receptors are at higher risk. There is an increase in antibodies such as TSHR and IGF-1R.

What are the symptoms of Graves' ophthalmopathy?

Symptoms include staring eyes, eyelid retraction, bulging eyes, double vision, dull, deep eye discomfort, tearing, photophobia, and even blurred vision.

Are there early, moderate, and late-stage symptoms? According to the European Group EUGOGO Consensus of Graves Orbitopathy, Graves' ophthalmopathy can be classified into MILD, MODERATE-SEVERE, and SIGHT-THREATENING Graves' ophthalmopathy.

MILD stage has a minor impact on the quality of life with mild lid retraction less than 2mm, minor soft tissue involvement, and exophthalmos less than 3mm.

MODERATE-SEVERE stage has a more significant impact on quality of life with either lid retraction more than 2mm, exophthalmos more than 3mm, moderate to severe soft tissue involvement, or double vision (diplopia).

SIGHT-THREATENING stage is where patients have Dysthyroid Optic Neuropathy or exposure keratopathy with sight-threatening corneal breakdown. These patients need immediate intervention.

Which demographic is at a higher risk? What factors contribute to this increased risk?

Risk factors include female sex, middle age, smoking, genetics, and selenium deficiency.

1. Epidemiology shows that women are four times more likely to have it than men.
2. Peak incidence rates are in the middle age group, being 40-44 in women and 45-49 in men.
3. Smokers are seven times more likely to develop thyroid eye disease compared to non-smokers.
4. Genetics: HLA-DR3, HLA-B8, genes for CTLA4, TSH receptors, increase in antibodies such as TSHR and IGF-1R.
5. Selenium deficiency: Cao et al (2022) reported that Selenium deficiency is a risk factor for Graves' ophthalmopathy, and selenium supplementation has been an adjuvant therapy.

How is the diagnosis of Graves' ophthalmopathy typically confirmed?

Diagnosis is confirmed with 2 out of 3 signs of the disease as below:

1. Blood investigation indicating thyroid antibodies, evidence of Graves hyperthyroidism.
2. Orbital signs – Eyelid retraction/ restricted extraocular muscle movement, compressive optic neuropathy, fluctuating eyelid edema and redness, chemosis/caruncular edema.
3. Radiographic evidence (CT scan) of Thyroid eye disease with fusiform enlargement of extraocular muscles.

What are the treatment options for Graves' ophthalmopathy? How can individuals with Graves' ophthalmopathy prevent the condition from worsening?

Treatment for Graves' ophthalmopathy depends on the Stages. The Physician/ Endocrinologist and Ophthalmologist will work together to treat the patient. The Physician plays an important role in restoring Euthyroid in patients in all stages. Thyroid Function Tests need to be monitored.

In MILD Graves' ophthalmopathy, lubricant eyedrops are prescribed with night ointments. Prism may offer some symptomatic relief. Patients are urged to quit smoking, if any. Selenium supplements are advised.

In MODERATE-SEVERE Graves' ophthalmopathy, immunosuppressants like glucocorticoids are indicated. Orbital Radiotherapy is also an option.

In SIGHT-THREATENING Dysthyroid Optic Neuropathy, urgent treatment with intravenous glucocorticoids is needed. If the response is poor, surgical decompression is warranted! Once Graves' ophthalmopathy is stable and inactive, there is a role for rehabilitation surgery.

Can Graves' ophthalmopathy lead to blindness? If so, is it temporary or permanent?

YES! In SIGHT-THREATENING Dysthyroid Optic Neuropathy, patients lose their vision. If not treated urgently, this blindness can become permanent. Therefore, all patients with Graves' ophthalmopathy should see an ophthalmologist and follow up closely.

Are there preventive measures for Graves' ophthalmopathy?

Certainly. Early diagnosis and early treatment can prevent the progression of Graves' ophthalmopathy. Treating these patients at early stages, rendering them euthyroid early, can prevent progression to later stages and prevent sight-threatening complications. Therefore, I urge all patients with symptoms of Graves' ophthalmopathy to see a physician and ophthalmologist early. Remember that early intervention and watchful monitoring can save sight!

This article was contributed by Dr. Jocelyn Wu Shin Yin, Consultant Ophthalmologist and Eye Surgeon at Pantai Hospital Klang. To book an appointment or learn more about Dr. Jocelyn Wu Shin Yin and her clinic, click here.