Grave's exophthalmos

Question 1

Define the term exophthalmos

Answer 1

proptosis of the eyeball out of the socket

In the case of Grave’s it is bilateral

Question 2

Exophthalmos is a unique feature of which thyroid disease

Answer 2

Grave’s disease

Question 3

What percentage of patient with Grave’s disease is affected by exophthalmos

Answer 3

Affects between 25-50% of patients with Graves’ disease.

Question 4

Name the two risk factors for Grave’s exophthalmos

Answer 4

· Family history of autoimmune disease, particularly Grave’s disease

· Smoking worsens the disease

Question 5

In respect to Grave’s disease, at what stage of the disease progression does exophthalmos usually present

Answer 5

Onset may precede the presentation of hyperthyroidism or follow its treatment

Question 6

Grave’s disease is an example of an autoimmune ____

a) Hyperthyroidism
b) Hypothyroidism

Answer 6

Grave’s disease is an example of an autoimmune Hyperthyroidism

Question 7

Describe the pathogenesis of Grave’s disease

Answer 7

TSH receptor autoantibodies are produced by the immune system which mimics TSH

These antibodies stimulate the TSH receptors on the thyroid causing hyperthyroidism

Question 8

Describe the pathogenesis of Grave’s exophthalmos

Answer 8

Pathogenesis of Grave’s exophthalmos is not fully understood

Off target effect of the TSH receptor autoantibodies causes retro-orbital inflammation, swelling and hypertrophy

The inflammation results in glycosaminoglycan and collagen deposition in the extra-ocular muscles

Question 9

Name some of the clinical features of Grave’s exophthalmos

Answer 9

• Proptosis - most common feature
• Periorbital oedema
• Lid retraction
• Eye pain
• Visual loss - sign of severe disease

Question 10

For mild Grave’s exophthalmos what are the two components of management

Answer 10

Topical lubricants e.g. artificial tears

Smoking cessation

Question 11

When should we refer to ophthalmology in Grave’s exophthalmos

Answer 11

If there is evidence of optic nerve compression, corneal opacity or inability to close an eye

Question 12

What are the three treatment options the ophthalmologist may suggest for a patient with severe Grave’s exophthalmos

Answer 12

Steroids

Radiotherapy

Surgical decompression

Question 13

Name the three unique features of Grave’s disease

Answer 13

Bilateral exophthalmos (Graves’ ophthalmopathy)

Pretibial myxoedema

Thyroid acropachy - characterised by periostitis, nail clubbing and soft tissue swelling of the extremities

Periostitis is inflammation of the periosteum, a layer of connective tissue that surrounds bone.