Graves’ Ophthalmopathy

• more common in men and cigarette smokers. 
• Exacerbated by radioiodine therapy and poor control of thyroid function, especially hypothyroidism. 
• Excessive lacrimation made worse by wind and bright light.
• A ‘gritty’ sensation in the eyes.
• Pain due to conjunctivitis or corneal ulceration.
• Reduction of visual acuity and/or visual fields due to corneal oedema or optic nerve compression
• Signs of optic nerve compression: reduced color vision, relative afferent pupillary defect 
• Diplopia: if the extraocular muscles are involved 

Treatment:

• • Reassurance. 
  • Smoking cessation. 
  • Spectacle with tinted glasses or side shields 
  • Methylcellulose eye drops and gel → for gritty discomfort of dry eyes, 
  • In mild case: 
    • oral selenium (100 µg twice daily for 6 months) → antioxidant effect. 

• Moderate to severe ophthalmopathy 

1. glucocorticoids (e.g. pulsed intravenous methylprednisolone) 
2. orbital radiotherapy. 
3. immunosuppressive therapies (e.g. rituximab, tocilizumab) 
4. IGF-1 receptor inhibitor: teprotumumab 

• • Loss of visual acuity 
    • urgent surgical decompression of the orbit. 

• In ‘burnt-out’ disease

• surgery to the extraocular muscles

The “NO SPECS” scoring system to evaluate ophthalmopathy is an acronym derived from the following changes: (harrison)

• N = No signs or symptoms 
• O= Only signs (lid retraction or lag), no symptoms 
• S = Soft tissue involvement (periorbital edema) 
• P= Proptosis (>22 mm) 
• E= Extraocular muscle involvement (diplopia) 
• C= Corneal involvement 
• S= Sight loss