(Graves Ophthalmopathy) Thyroid eye disease is a syndrome of clinical and orbital imaging abnormalities caused by deposition of mucopolysaccharides and infiltration with chronic inflammatory cells of the orbital tissues, particularly the extraocular muscles It usually occurs in association with autoimmune hyperthyroidism Clinical or laboratory evidence of thyroid dysfunction and thyroid antibodies may not be detectable at presentation or even on long-term follow-up, but their absence requires consideration of other disease entities Radioiodine therapy, possibly indirectly due to induction of hypothyroidism, and cigarette smoking increase the severity of thyroid eye disease and ethanol injection of thyroid nodules has been reported to be followed by severe disease (see Chapter 26) Ocular myasthenia and thyroid eye disease are associated and may coexist, the presence of ptosis rather than lid retraction being more characteristic of the former

Clinical Findings

The primary clinical features are proptosis, lid retraction and lid lag, conjunctival chemosis and episcleral inflammation, and extraocular muscle dysfunction Resulting symptoms are cosmetic abnormalities, surface irritation, which usually responds to artificial tears, and diplopia, which should be treated conservatively (eg, with prisms) in the active stages of the disease and only by surgery when the disease has been static for at least 6 months The important complications are corneal exposure and optic nerve compression, both of which may lead to marked visual loss The primary imaging features are enlargement of the extraocular muscles, usually affecting both orbits The clinical and imaging abnormalities of thyroid eye disease may be mimicked by dural carotico-cavernous sinus fistula

When to Refer

All patients with thyroid eye disease should be referred to an ophthalmologist, urgently if there is reduced vision