Graves Ophthalmology

Graves’ ophthalmopathy, also known as Graves’ orbitopathy, Graves’ eye disease, or thyroid eye disease, is an autoimmune condition that develops in people with an overactive thyroid. The condition causes swelling of the tissue in the area around the eye, leading to the bulging of the eyes.

Graves’ ophthalmopathy, also known as Graves’ orbitopathy, Graves’ eye disease, or thyroid eye disease, is an autoimmune condition that develops in people with an overactive thyroid. The condition causes swelling of the tissue in the area around the eye, leading to the bulging of the eyes. It is associated with Graves’ disease, an immune system disorder that results in the overproduction of thyroid hormones. Almost 30% of the people with Graves’ disease have some symptoms of Graves’ ophthalmopathy.

1. The exact cause of Graves’ ophthalmopathy is unknown, but it may be associated with genetic and environmental factors. 
2. It is an autoimmune disorder wherein the thyroid gland incorrectly detects cancerous cells and produces antibodies to fight them. Because there are no harmful cells, the released antibodies bind to muscles in the eyes, resulting in Graves' disease. 
3. The condition often develops simultaneously with hyperthyroidism, but the signs may appear years before or after hyperthyroidism’s onset. 
4. It can develop even when there is no hyperthyroidism. 

The symptoms of Graves’ ophthalmopathy include:-

1. Inflammation or redness in the eye
2. Bulging of eyes
3. Dry eyes
4. Eye irritation
5. Gritty sensation in the eyes
6. Pressure or pain in the eyes
7. Swelling of eyelids
8. Retracted eyelids
9. Sensitivity to light
10. Double vision
11. Vision loss

The factors that can increase the risk of developing Graves’ ophthalmopathy include:-

1. Genetic Influences: People with a family history of Graves’ ophthalmopathy are more susceptible to the disease. 
2. Smoking: Smoking cigarettes increases the risk of Graves’ ophthalmopathy. If you have Graves’ disease and smoke, you’re five times more likely to develop this eye disease than people who do not smoke. 
3. Sex: Women are at an increased risk of developing Graves’ ophthalmopathy than men. 
4. Stress: Emotional or physical stress is another factor that can trigger the disease who have genes that increase the risk. 
5. Therapy: People who have undergone iodine therapy for hyperthyroidism can also develop Graves’ ophthalmopathy.

If you have Graves’ disease and experience the symptoms of Graves’ ophthalmopathy, your doctor may recommend you to see an ophthalmologist. The doctor will check your eyes for enlarged or bulging muscles. You may need to undergo one or more of the following tests to diagnose the condition:-

1. Ultrasound: It uses high-frequency sound waves to measure and produce pictures of the structures around your eyes. 
2. CT scan: It is a powerful X-ray to take detailed pictures of the inside of your eye.
3. MRI: It takes pictures of your eye muscles using a strong magnetic field and radio waves. 
4. Blood test: It measures the level of antibodies or thyroid hormones in your blood. 

Some other tests for Graves’ ophthalmopathy include:-

1. Visual field test
2. Vision test
3. Optic nerve test
4. Eye pressure reading
5. Eyelid measurements

Treatment for Graves’ ophthalmopathy is a joint effort by your primary care doctor (endocrinologist) to get your hormone levels in a normal range and an eye specialist (ophthalmologist) to treat the symptoms. The treatment for Graves’ ophthalmopathy includes:-

1. Medication: Teprotumumab (Tepezza) is the first drug approved to treat Graves’ ophthalmopathy. It blocks the antibodies that attack the tissues behind the eyes and helps reduce symptoms like double vision and eye bulging. 
2. Prism glasses: The doctor may prescribe prism glasses if double vision is a problem. These glasses bend the light so that it lands in the right place. 
3. Radiation: The doctor uses beams of intense energy to relieve double vision and reduce swelling. However, radiation treatment can have side effects like dry eyes or an increased risk for cancer. 
4. Steroids: Steroids like prednisone and hydrocortisone can help relieve swelling in your eyes and treat double vision. Doctors prescribe steroids only for a short duration as they have side effects like mood swings, weight gain, and high blood pressure. 
5. Home Remedies:-
   1. Use lubricating eye drops: Eye drops, like artificial tears, can help relieve dryness and scratchy feeling in the eyes. Before sleeping, you can use a lubricating gel to prevent your cornea from drying if your eyelids do not close fully. 
   2. Apply cool compresses: Gently press a wet washcloth to your eyes for temporary relief from irritation. 
   3. Wear sunglasses: Wearing sunglasses can help with light sensitivity and protect your eyes from ultraviolet rays, wind, or breeze. 
   4. Sleep with your head raised: Keep your head higher than the rest of your body while sleeping to help reduce swelling and relieve pressure on your eyes. 

1. Reduces the bulge in the eye(s).
2. Improves vision if the swollen muscles behind the eye have squeezed the optic nerve.
3. Relives the symptoms like grittiness and watering of the eyes
4. Reduces the staring appearance of the eyes.

The complications of delaying treatment for Graves’ ophthalmopathy include mild signs like conjunctival inflammation and eye dryness. It can even lead to severe vision-threatening risks such as corneal ulcers, optic nerve compression, and extraocular muscle entrapment. If left untreated, graves’ ophthalmopathy can also threaten your eyesight, resulting in irreversible vision loss. 

Disease Progression of Graves’ Ophthalmopathy

Graves’ ophthalmopathy progresses in two phases:-

1. The active or acute phase: This is the inflammatory phase where symptoms develop suddenly and get worse quickly. The stage lasts for six months to two years. The focus is on treatment to remove the eye symptoms during this stage. 
2. The stable or chronic phase: Inflammation and other symptoms subside during this stage. Many patients may be left with more visible effects of the disease, such as eyelid retraction, misaligned eyes, and double vision, that may require additional treatments like surgery.