Sometimes it is called Graves orbitopathy or sometimes thyroid eye disease.
There is definitely a connection with thyroid disease but it is not necessarily a thyroid problem.
This is a form of auto-immune disease. A lot of auto-immune diseases are due to antibodies.
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| The antibody protein usually has this Y shape |
Antibodies are proteins that the body makes to fight off infections. So, they are supposed to target bacteria and viruses. However, occasionally the immune system gets confused and makes antibodies that affect normal, otherwise healthy tissue and the antibody causes disease. So in the case of Graves disease the body makes an antibody called Thyroid Stimulating Immunoglobulin (TSI). The most common target of this antibody is the thyroid gland. It will attach to the thyroid receptors and crank up the production of thyroid hormones. This action is called hyperthyroid state. However, those antibodies may also target the cells in the eye sockets also called orbits. When the antibodies attack the orbits they can cause swelling of the tissues and thickening of the eye mucles.
So, these antibodies can attack the thyroid and/or the eye sockets. That's why it is connected to thyroid disease but not necessarily a thyroid problem. Patients can have the thyroid issues, the eye issues or both. It also means treating the thyroid won't automatically treat the eyes and vice versa.
The thyroid disease is treated by an endocrinologist.
The eye disease is treated by a team of eye doctors.
All of the symptoms of Graves Orbitopathy are due to the tissue swelling and muscle thickening.
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| This MRI shows a very large muscle behind one of the eyes. That large muscle is going to cause bulging of the eye and double vision since it is so thick and tight. Graves Orbitopathy can affect just one eye muscle or a few eye muscles or all of the eye muscles. |
1 Swelling causes bulging eyes, and bulging eyes get dry and irritated and painful.
2 Eyelid muscle thickening causes the eyes to open up widely and that also increases the exposure of the eye and leads to dryness and irritation and pains.
3 Thickened eye muscles cause the eyes to go out of alignment or even get stuck and that will cause double vision.
4 Really bad swelling can lead to compression of the nerve tissue in the eye socket and can actually cause vision loss. (This is, fortunately, rare.)
Treatment for Graves disease is generally two categories: medical management and surgical management.
For a long time we didn't have any good treatments and patients were treated with steroids or radiation. However, there is now an infusion available that can reduce tissue swelling in Graves Orbitopathy patients. It is called teprotumumab. It is a bit of a commitment to start teprotumumab. It is administered as an infusion every 3 weeks for 8 treatments. So, it takes nearly 6 months to complete the whole course.
If medication isn't an option or if it fails to completely treat the symptoms then surgical management is an option. If surgeries are needed, then they should be done in order. If there is severe crowding then an orbital decompression surgery is first. Then if there is double vision, strabismus surgery or eye muscle repositioning is done next. If there is eyelid asymmetry then a lid alignment procedure would be last.
In summary, Graves Orbitopathy is associated with thyroid disease but is an independent disease process. Inflammation causes tissue swelling which causes bulging eyes and misaligned eyes. Treatment can be done with infusions but sometimes surgery is still needed.