Graves Disease
- Autoimmune process that targets thyroid gland, orbital tissues
- Systemic manifestations include hyperthyroidism and hypothyroidism
- Serum markers include elevated thyroid-stimulating immunoglobulin
- Disease divided into active phase (inflammation) and inactive phase (scarring)
- Ophthalmic manifestations: lid retraction, lid lag, proptosis, conjunctival inflammation, tearing, ocular misalignment, optic neuropathy
- Discomfort around eyes rather than pain
- Symptoms appear gradually and depend on which signs are present
- Lid retraction: lower border of upper lid does not reach top of cornea, so that some sclera shows
- Lig lag: upper lids do not keep pace with eyes on downward gaze, so that sclera shows until upper lids catch up
- Proptosis (exophthalmos): forward displacement of eye because of retrobulbar soft tissue swelling
- Conjunctival inflammation: diffuse congestion with dilated blood vessels and conjunctival swelling
- Tearing: because conjunctiva inflamed
- Ocular misalignment: extraocular muscles become inflamed and stiff, preventing full eye movement
- Optic neuropathy: extraocular muscles enlarge enough to compress optic nerve in posterior orbit
- Swollen extraocular muscles apparent on orbital CT or MRI
- Orbital cellulitis, but usually faster onset, unilateral, and no lid retraction
- Idiopathic orbital inflammation, but usually more pain, more unilateral, and no lid retraction or lag
- Orbital tumor, but usually unilateral, and no lid retraction or lag
- Carotid-cavernous arteriovenous fistula, but superior ophthalmic vein dilated on imaging
- Conjunctivitis causes no proptosis, lid lag, or lid retraction
- Contact dermatitis affects only lids and surrounding facial skin
- Stye causes focal swelling and tenderness mainly affecting one lid
- Dacryocystitis causes focal swelling and tenderness of nasal portion of lower lid, where lacrimal sac lies
- Anterior uveitis causes photophobia
- Scleritis usually causes focal conjunctival redness and more periocular pain
- Refer non-urgently to ophthalmologist
- Refer more urgently if patient expresses marked pain or vision loss
- Regulation of thyroid function does not alter course of ophthalmic findings
- Head-of-bed elevation, topical decongestants treat mild conjunctival inflammation
- Short-term corticosteroids treat marked ocular discomfort, conjunctival inflammation, ocular misalignment
- Lubricants and moisture chambers treat severe proptosis with corneal exposure
- Orbital wall surgical decompression treats corneal exposure, optic neuropathy
- Spectacle prisms and extraocular muscle surgery treat ocular misalignment once disease enters inactive phase
- Lid-lowering surgery treats lid retraction
- Outcomes depend on severity of disease and timing of interventions