Graves Disease (Hyperthyroid Eye Disease )

What is Graves Disease (Hyperthyroid Eye Disease )?

Graves’ disease is a condition where the body’s immune system mistakenly attacks the thyroid gland, which is a small organ located at the base of your neck. It can also impact various other parts of the body like the eyes and skin. This disease is the main reason for hyperthyroidism, a condition where the thyroid works more than it should. This article aims to cover the various aspects of Graves’ disease.

What Causes Graves Disease (Hyperthyroid Eye Disease )?

Autoimmune diseases, including this one, tend to occur more frequently in people with a family history of such diseases. Additionally, this disease shows up more often in identical twins compared to fraternal twins.

Various environmental factors can trigger this disease. These factors include stress, smoking, infections, exposure to iodine, and the period after childbirth. It has also been found to occur after treatment with highly active antiretroviral therapy (HAART), which helps boost the immune system.

Risk Factors and Frequency for Graves Disease (Hyperthyroid Eye Disease )

Graves’ disease is the main cause of an overactive thyroid, or hyperthyroidism, and it accounts for 60% to 80% of these cases. In the United States, around 1.2% people suffer from hyperthyroidism, with new cases ranging from 20 to 50 per 100,000 people. It primarily affects individuals between the ages of 20 to 50 and is more prevalent in women than in men. Research indicates that the risk of developing Graves’ disease during one’s lifetime is 3% in women and 0.5% in men. According to a study, in women aged between 25 to 42, the rate of new cases over a span of 12 years was as high as 4.6 per 1,000.

Graves’ disease is the leading cause of hyperthyroidism, accounting for 60-80% of cases.
Around 1.2% of people in the United States are diagnosed with hyperthyroidism.
The rate of new cases ranges from 20 to 50 per 100,000 people.
This disease is most common among those aged 20 to 50.
It is more prevalent in women than in men.
The lifetime risk for women is 3% and for men it’s 0.5%.
A study found that in women aged 25 to 42, the rate of new cases over 12 years was 4.6 per 1,000.

Signs and Symptoms of Graves Disease (Hyperthyroid Eye Disease )

Graves’ disease often shows up in patients with clear signs of an overactive thyroid. However, it can sometimes only show up as specific conditions related to Graves’ disease, such as eye problems or a type of leg swelling called pretibial myxedema. How it appears can depend on a person’s age, how severe their overactive thyroid is, and how long it has been overactive. Older people might only show unclear symptoms like feeling worn out, losing weight, and developing irregular heart rhythms. In some cases, they might not show the typical symptoms of an overactive thyroid, which is known as apathetic thyrotoxicosis.

In younger patients, Graves’ disease commonly appears as a sensitivity to heat, excessive sweating, fatigue, weight loss, a rapidly beating heart, too frequent bowel movements, and shaking. Further symptoms can include sleep problems, feeling nervous or anxious, being overly active, having difficulties in breathing, muscle weakness, itching, needing to urinate a lot, and irregular or absent periods in women. Men may experience a loss in sex drive, while others might feel fullness in the neck. Eye symptoms such as swollen eyelids, eye pain, reddening of the area around the eye, and double vision may also occur. A condition known as goiter, which causes the neck to swell, is more common in younger people, specifically those under 60. However, roughly 10% of patients might actually put on weight.

Physical signs of an overactive thyroid include fast heart rate, high blood pressure, signs of heart failure (like fluid buildup, crackling sounds in the lungs due to fluid buildup, bulging veins in the neck, rapid breathing), irregular heart rhythms, minor shaking, reduced control over movements, increased reflexes, warm and damp skin, red palms and lifting of the nail from the nail bed, hair loss, swollen thyroid gland with a noise that can be heard through a stethoscope and altered mental state.

Moreover, visible signs of Graves’ disease include problems with the eyes like eyelid retraction, bulging eyes, swelling around the eyes, watery and puffy eyes, redness in the white of the eye, and corneal abrasion. A skin condition due to Graves’ disease can cause significant skin thickening, primarily over the lower leg bones, though this is a rare occurrence, seen in 2% to 3% of cases. The thickened skin takes on an orange-peel texture and is hard to pinch. Effects on bones can include new bone formation and swelling in the bones of the hand, which is known as thyroid acropachy. Lifted nails (Plummer nails) and clubbing, or widening and rounding of the ends of the fingers, are very rare.

Testing for Graves Disease (Hyperthyroid Eye Disease )

Diagnosing Graves’ disease involves a complete history check and physical examination, which should also include your family history of the disease. There are specific tests doctors use to identify this condition:

At first, doctors use a thyroid-stimulating hormone test, also known as the TSH test, to diagnose hyperthyroidism. If the results show a decreased TSH level, they will proceed to the next set of tests, which includes Free T4 (FT4) and Free T3 (FT3). If these are not accessible, they will ask for total T4 (Thyroxine) and total T3 (Triiodothyronine). A diagnosis of hyperthyroidism can be confirmed if the TSH is low and either the FT4 or FT3 or both are high. However, if only the TSH is low but FT4 and FT3 results are normal, this may suggest a mild form of hyperthyroidism.

To differentiate Graves’ disease from other causes of hyperthyroidism, several tests can be ordered:

The TSH receptor antibody (TRAb) is one such test. There are two types TRAb tests available – thyroid stimulating immunoglobulin (TSI) and the thyrotropin-binding inhibitory immunoglobulin or TBII. These tests are particularly useful in certain situations, such as hyperthyroidism during pregnancy, Graves’ disease without biochemical hyperthyroidism, or when there is a possibility of hyperthyroidism in fetuses and newborns, among others.

Another test employed is the radioactive iodine uptake scan with I-123 or I-131. Here, the uptake will be high and widespread in cases of Graves’ disease as opposed to a toxic nodule or multiple nodules causing hyperthyroidism, where the uptake will be focal or heterogeneous, respectively.

Furthermore, a thyroid ultrasound with Doppler may be performed as the thyroid gland in Graves’ disease usually has an increased blood flow. Another method to differentiate Graves’ disease from thyroiditis-induced thyrotoxicosis is by comparing the ratio of T3/T4 or FT3/FT4 levels.

There are other tests like CT or MRI scans, typically used to diagnose Graves’ orbitopathy, which is an eye condition connected to Graves’ disease.

Finally, patients with hyperthyroidism may have low red blood cell count or platelets, increased bilirubin or liver enzymes, high calcium or alkaline phosphatase levels, and low LDL and HDL cholesterol. These may need to be checked too.

Treatment Options for Graves Disease (Hyperthyroid Eye Disease )

The treatment for Graves’ disease, a condition where the immune system attacks the thyroid and causes it to become overactive, focuses on quickly alleviating symptoms and regulating the production of thyroid hormones.

As initial care, doctors generally prescribe beta blockers, particularly for patients with high heart rates, heart disease, or the elderly. A commonly used beta blocker is Atenolol, taken orally once a day. If beta blockers are ineffective, heart rates can also be controlled with calcium channel blockers like diltiazem and verapamil.

There are three main methods used to reduce the production of thyroid hormones:

1. Prescription medications, known as antithyroid drugs, that block the synthesis and release of these hormones.
2. Treating the thyroid gland with radioactive iodine (RAI).
3. Undergoing surgery to remove part or all of the thyroid gland.

All methods have pros and cons, and the best course of action would vary by patient.

Antithyroid drugs are generally the preferred method of treatment outside of pregnancy. Methimazole is used because of its lower frequency of side effects and convenience of once-daily dosing. If a patient is in the first trimester of pregnancy, propylthiouracil is the recommended drug to avoid possible side effects for the embryo. Propylthiouracil is also recommended for some other specific cases, such as refusal of surgery or in a thyroid storm.

Patients should be aware of any potential side effects before starting treatment, including allergic reactions or liver damage. The medication regime begins with higher doses, which are then reduced over time once thyroid function tests indicate a return to normal levels.

Radioactive iodine therapy is often recommended for adult patients who are not pregnant, those at a high risk during surgery, and patients who cannot take antithyroid drugs. However, it is not recommended during pregnancy, lactation, or in cases of coexisting thyroid cancer.

Surgical removal of the thyroid is typically reserved for larger cases or for patients with cancerous nodules or certain complications associated with Graves’ disease.

Apart from these primary treatments, other options, such as iodinated contrast agents and glucocorticoids, have been tested. Additionally, the treatment of Graves’ orbitopathy, a condition affecting the eyes, often accompanies treatment for Graves’ disease itself. In this case, early achievement of normal thyroid hormone levels and quitting smoking are key, with doctors also considering different therapeutic options depending on the severity of symptoms.

There is no definitive treatment available for other symptoms associated with Graves’ disease, such as the skin condition known as Graves’ dermopathy or the severe form of skin and tissue thickening known as acropachy.

External intake of thyroid hormones
Hashimoto’s disease, an autoimmune disorder affecting the thyroid gland
Hyperemesis gravidarum, severe nausea and vomiting during pregnancy
Papillary thyroid cancer, a common type of thyroid cancer
Pheochromocytoma, a tumor usually found in the adrenal glands
Pituitary resistance to thyroid hormone, a condition where the pituitary gland is unresponsive to thyroid hormones
Postpartum thyroiditis, an inflammation of the thyroid after giving birth
Radiation-induced thyroiditis, an inflammation of the thyroid caused by radiation therapy
Silent thyroiditis, a painless thyroid inflammation
Struma ovarii, a rare condition where the thyroid gland develops within the ovaries
Subacute thyroiditis, a condition with painful thyroid gland inflammation
Thyrotropin-producing pituitary adenomas, benign tumors in the pituitary gland that produce thyroid-stimulating hormones
Toxic multinodular goiter, lumps in the thyroid gland resulting in excess hormones

Possible Complications When Diagnosed with Graves Disease (Hyperthyroid Eye Disease )

Thionamides, a type of medication, can sometimes cause agranulocytosis, a severe and dangerous reduction in the number of white blood cells in the body. Additionally, the use of these drugs may also worsen hyperthyroidism, a condition where the thyroid gland produces excessive hormones.

Potential Side Effects:

Agranulocytosis related to the thionamides
Exacerbation of hyperthyroidism

Frequently asked questions

Graves' disease is a condition where the body's immune system mistakenly attacks the thyroid gland, causing hyperthyroidism. It can also affect other parts of the body, including the eyes and skin.

Graves' disease is the leading cause of hyperthyroidism, accounting for 60-80% of cases.

Signs and symptoms of Graves' Disease (Hyperthyroid Eye Disease) include: - Sensitivity to heat - Excessive sweating - Fatigue - Weight loss - Rapidly beating heart - Too frequent bowel movements - Shaking - Sleep problems - Feeling nervous or anxious - Being overly active - Difficulties in breathing - Muscle weakness - Itching - Needing to urinate a lot - Irregular or absent periods in women - Loss in sex drive in men - Fullness in the neck - Swollen eyelids - Eye pain - Reddening of the area around the eye - Double vision - Goiter (neck swelling), more common in younger people - Weight gain (in approximately 10% of patients) Physical signs of an overactive thyroid associated with Graves' Disease include: - Fast heart rate - High blood pressure - Signs of heart failure (fluid buildup, crackling sounds in the lungs, bulging veins in the neck, rapid breathing) - Irregular heart rhythms - Minor shaking - Reduced control over movements - Increased reflexes - Warm and damp skin - Red palms and lifting of the nail from the nail bed - Hair loss - Swollen thyroid gland with a noise that can be heard through a stethoscope - Altered mental state Visible signs of Graves' Disease include: - Eyelid retraction - Bulging eyes - Swelling around the eyes - Watery and puffy eyes - Redness in the white of the eye - Corneal abrasion Rare occurrences associated with Graves' Disease include: - Significant skin thickening, primarily over the lower leg bones, with an orange-peel texture that is hard to pinch - New bone formation and swelling in the bones of the hand (thyroid acropachy) - Lifted nails (Plummer nails) - Clubbing, or widening and rounding of the ends of the fingers

Various environmental factors can trigger Graves' disease, including stress, smoking, infections, exposure to iodine, the period after childbirth, and treatment with highly active antiretroviral therapy (HAART). Additionally, Graves' disease tends to occur more frequently in people with a family history of autoimmune diseases.

The conditions that a doctor needs to rule out when diagnosing Graves' Disease (Hyperthyroid Eye Disease) are: - External intake of thyroid hormones - Hashimoto's disease, an autoimmune disorder affecting the thyroid gland - Hyperemesis gravidarum, severe nausea and vomiting during pregnancy - Papillary thyroid cancer, a common type of thyroid cancer - Pheochromocytoma, a tumor usually found in the adrenal glands - Pituitary resistance to thyroid hormone, a condition where the pituitary gland is unresponsive to thyroid hormones - Postpartum thyroiditis, an inflammation of the thyroid after giving birth - Radiation-induced thyroiditis, an inflammation of the thyroid caused by radiation therapy - Silent thyroiditis, a painless thyroid inflammation - Struma ovarii, a rare condition where the thyroid gland develops within the ovaries - Subacute thyroiditis, a condition with painful thyroid gland inflammation - Thyrotropin-producing pituitary adenomas, benign tumors in the pituitary gland that produce thyroid-stimulating hormones - Toxic multinodular goiter, lumps in the thyroid gland resulting in excess hormones

To properly diagnose Graves' Disease (Hyperthyroid Eye Disease), the following tests may be ordered by a doctor: 1. Thyroid-stimulating hormone (TSH) test: This test is used to diagnose hyperthyroidism. If the TSH level is decreased, further tests will be conducted. 2. Free T4 (FT4) and Free T3 (FT3) tests: These tests measure the levels of thyroid hormones in the blood. If the TSH is low and either the FT4 or FT3 or both are high, it confirms a diagnosis of hyperthyroidism. 3. TSH receptor antibody (TRAb) test: This test helps differentiate Graves' Disease from other causes of hyperthyroidism. It can be useful in certain situations, such as hyperthyroidism during pregnancy or Graves' Disease without biochemical hyperthyroidism. 4. Radioactive iodine uptake scan: This scan helps differentiate Graves' Disease from other causes of hyperthyroidism. In Graves' Disease, the uptake will be high and widespread. 5. Thyroid ultrasound with Doppler: This test may be performed to assess the blood flow in the thyroid gland, as Graves' Disease usually has increased blood flow. 6. CT or MRI scans: These scans may be used to diagnose Graves' orbitopathy, an eye condition associated with Graves' Disease. Other tests may also be ordered to check for associated complications or abnormalities, such as low red blood cell count or platelets, increased bilirubin or liver enzymes, high calcium or alkaline phosphatase levels, and low LDL and HDL cholesterol.

The treatment for Graves' orbitopathy, also known as Hyperthyroid Eye Disease, often accompanies treatment for Graves' disease itself. The primary focus is on achieving normal thyroid hormone levels and quitting smoking. Doctors also consider different therapeutic options depending on the severity of symptoms. Other treatments, such as iodinated contrast agents and glucocorticoids, have been tested for this condition. However, there is no definitive treatment available for other symptoms associated with Graves' disease, such as Graves' dermopathy or acropachy.

The side effects when treating Graves' Disease (Hyperthyroid Eye Disease) include: - Agranulocytosis related to the thionamides - Exacerbation of hyperthyroidism

An endocrinologist.

Hormones and Body Chemistry Hyperthyroid Eye Disease