Download PDF
Semin Plast Surg 2007; 21(1): 065-073
DOI: 10.1055/s-2007-967751
Copyright © 2007 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Thyroid-Associated Orbitopathy[*]

Adel H. Alsuhaibani1 , Jeffrey A. Nerad1
  • 1Oculoplastic, Orbital and Oncology Service, Department of Ophthalmology and Visual Sciences, University of Iowa Hospital and Clinics, Iowa City, Iowa
Further Information

Publication History

Publication Date:
05 March 2007 (online)

    Permissions and Reprints

ABSTRACT

Thyroid-associated orbitopathy (TAO) is usually diagnosed clinically. Early presentation of TAO such as ocular irritation, lid puffiness, and mild retraction may be overlooked and misdiagnosed. Careful clinical evaluation, laboratory investigations, and orbital imaging studies are needed for diagnosing early TAO. Knowing the pathogenesis will open the door for obtaining directed and effective treatment for the inflammatory process in TAO. Most patients with mild to moderate active TAO are treated with observation alone as the available treatment modalities effective in controlling the disease have many potential side effects. Severe active TAO, compressive optic neuropathy, and severe exposure keratopathy are the main indications for treatment with immunosuppressant agents, orbital radiotherapy, or orbital decompression. Surgery remains the final rehabilitation in TAO, which should be done during cicatricial (inactive) TAO when reliable and stable results can be obtained.

KEYWORDS

Thyroid-associated orbitopathy - Graves' ophthalmopathy - proptosis - lid retraction

1 The authors have no conflicts of interest or proprietary interest in any of the instruments or topics presented in this manuscript.

REFERENCES

  • 1 Wiersinga W M, Smit T, van der Gaag R et al.. Clinical presentation of Graves' ophthalmopathy.  Ophthalmic Res. 1989;  21 73-82
    PubMedGoogle Scholar
  • 2 Durairaj V D, Bartley G B, Garrity J A. Clinical features and treatment of graves ophthalmopathy in pediatric patients.  Ophthal Plast Reconstr Surg. 2006;  22 7-12
    CrossrefPubMedGoogle Scholar
  • 3 Bartley G B, Fatourechi V, Kadrmas E F et al.. The incidence of Graves' ophthalmopathy in Olmsted County, Minnesota.  Am J Ophthalmol. 1995;  120 511-517
    PubMedGoogle Scholar
  • 4 Szucs-Farkas Z, Toth J, Kollar J et al.. Volume changes in intra- and extraorbital compartments in patients with Graves' ophthalmopathy: effect of smoking.  Thyroid. 2005;  15 146-151
    CrossrefPubMedGoogle Scholar
  • 5 Eckstein A, Quadbeck B, Mueller G et al.. Impact of smoking on the response to treatment of thyroid associated ophthalmopathy.  Br J Ophthalmol. 2003;  87 773-776
    CrossrefPubMedGoogle Scholar
  • 6 Graves R J. Clinical lectures (part II).  London Med Surg J. 1835;  7 516-517
    PubMedGoogle Scholar
  • 7 Ozgen A, Alp M N, Ariyurek M et al.. Quantitative CT of the orbit in Graves' disease.  Br J Radiol. 1999;  72 757-762
    PubMedGoogle Scholar
  • 8 Bartley G B, Fatourechi V, Kadrmas E F et al.. Clinical features of Graves' ophthalmopathy in an incidence cohort.  Am J Ophthalmol. 1996;  121 284-290
    CrossrefPubMedGoogle Scholar
  • 9 Wiersinga W M, Smit T, van der Gaag R et al.. Temporal relationship between onset of Graves' ophthalmopathy and onset of thyroidal Graves' disease.  J Endocrinol Invest. 1988;  11 615-619
    Google Scholar
  • 10 Mourits M P, Koornneef L, Wiersinga W M et al.. Clinical criteria for the assessment of disease activity in Graves' ophthalmopathy: a novel approach.  Br J Ophthalmol. 1989;  73 639-644
    PubMedGoogle Scholar
  • 11 Grove Jr A S. Evaluation of exophthalmos.  N Engl J Med. 1975;  292 1005-1013
    PubMedGoogle Scholar
  • 12 Rothfus W E, Curtin H D. Extraocular muscle enlargement: a CT review.  Radiology. 1984;  151 677-681
    PubMedGoogle Scholar
  • 13 Streeten D H, Anderson Jr G H, Reed G F et al.. Prevalence, natural history and surgical treatment of exophthalmos.  Clin Endocrinol (Oxf). 1987;  27 125-133
    CrossrefPubMedGoogle Scholar
  • 14 Kadrmas E F, Bartley G B. Superior limbic keratoconjunctivitis. A prognostic sign for severe Graves' ophthalmopathy.  Ophthalmology. 1995;  102 1472-1475
    PubMedGoogle Scholar
  • 15 Henderson J W. Optic neuropathy of exophthalmic goiter (Graves' disease).  AMA Arch Ophthalmol.. 1958;  59 471-480
    PubMedGoogle Scholar
  • 16 Bahn R S, Heufelder A E. Pathogenesis of Graves' ophthalmopathy.  N Engl J Med. 1993;  329 1468-1475
    CrossrefPubMedGoogle Scholar
  • 17 Tallstedt L, Norberg R. Immunohistochemical staining of normal and Graves' extraocular muscle.  Invest Ophthalmol Vis Sci. 1988;  29 175-184
    PubMedGoogle Scholar
  • 18 Khurana A K, Sunder S, Ahluwalia B K et al.. Tear film profile in Graves' ophthalmopathy.  Acta Ophthalmol (Copenh). 1992;  70 346-349
    PubMedGoogle Scholar
  • 19 Smith T J, Bahn R S, Gorman C A. Connective tissue, glycosaminoglycans, and diseases of the thyroid.  Endocr Rev. 1989;  10 366-391
    PubMedGoogle Scholar
  • 20 Bahn R S. Thyrotropin receptor expression in orbital adipose/connective tissues from patients with thyroid-associated ophthalmopathy.  Thyroid. 2002;  12 193-195
    CrossrefPubMedGoogle Scholar
  • 21 Saravanan P, Dayan C M. Thyroid autoantibodies.  Endocrinol Metab Clin North Am. 2001;  30 315-337
    CrossrefPubMedGoogle Scholar
  • 22 Kubota S, Gunji K, Stolarski C, Kennerdell J S, Wall J. Reevaluation of the prevalences of serum autoantibodies reactive with “64-kd eye muscle proteins” in patients with thyroid-associated ophthalmopathy.  Thyroid. 1998;  8 175-179
    PubMedGoogle Scholar
  • 23 Dragan L R, Seiff S R, Lee D C. Longitudinal correlation of thyroid-stimulating immunoglobulin with clinical activity of disease in thyroid-associated orbitopathy.  Ophthal Plast Reconstr Surg. 2006;  22 13-19
    PubMedGoogle Scholar
  • 24 Gasser P, Flammer J. Optic neuropathy of Graves' disease. A report of a perimetric follow-up.  Ophthalmologica. 1986;  192 22-27
    PubMedGoogle Scholar
  • 25 Kahaly G J. Recent developments in Graves' ophthalmopathy imaging.  J Endocrinol Invest. 2004;  27 254-258
    CrossrefPubMedGoogle Scholar
  • 26 Bartley G B. The differential diagnosis and classification of eyelid retraction.  Ophthalmology. 1996;  103 168-176
    CrossrefPubMedGoogle Scholar
  • 27 Mombaerts I, Goldschmeding R, Schlingemann R O et al.. What is orbital pseudotumor?.  Surv Ophthalmol. 1996;  41 66-78
    CrossrefPubMedGoogle Scholar
  • 28 Nugent R A, Rootman J, Robertson W D et al.. Acute orbital pseudotumors: classification and CT features.  AJR Am J Roentgenol. 1981;  137 957-962
    CrossrefPubMedGoogle Scholar
  • 29 Harris G J. Idiopathic orbital inflammation: a pathogenetic construct and treatment strategy: The 2005 ASOPRS Foundation Lecture.  Ophthal Plast Reconstr Surg. 2006;  22 79-86
    PubMedGoogle Scholar
  • 30 Moster M L, Bosley T M, Slavin M L et al.. Thyroid ophthalmopathy presenting as superior oblique paresis.  J Clin Neuroophthalmol. 1992;  12 94-97
    PubMedGoogle Scholar
  • 31 Chen C C, Chang P C, Shy C G et al.. CT angiography and MR angiography in the evaluation of carotid cavernous sinus fistula prior to embolization: a comparison of techniques.  AJNR Am J Neuroradiol. 2005;  26 2349-2356
    PubMedGoogle Scholar
  • 32 Prummel M F, Wiersinga W M, Mourits M P et al.. Effect of abnormal thyroid function on the severity of Graves' ophthalmopathy.  Arch Intern Med. 1990;  150 1098-1101
    CrossrefPubMedGoogle Scholar
  • 33 Tallstedt L, Lundell G, Torring O et al.. Occurrence of ophthalmopathy after treatment for Graves' hyperthyroidism. The Thyroid Study Group.  N Engl J Med. 1992;  326 1733-1738
    Google Scholar
  • 34 Bartalena L, Marcocci C, Bogazzi F et al.. Relation between therapy for hyperthyroidism and the course of Graves' ophthalmopathy.  N Engl J Med. 1998;  338 73-78
    Google Scholar
  • 35 Wiersinga W M. Preventing Graves' ophthalmopathy.  N Engl J Med. 1998;  338 121-122
    CrossrefPubMedGoogle Scholar
  • 36 Bartalena L, Pinchera A, Marcocci C. Management of Graves' ophthalmopathy: reality and perspectives.  Endocr Rev. 2000;  21 168-199
    CrossrefPubMedGoogle Scholar
  • 37 Day R M, Carroll F D. Corticosteroids in the treatment of optic nerve involvement associated with thyroid dysfunction.  Arch Ophthalmol. 1968;  79 279-282
    PubMedGoogle Scholar
  • 38 Hiromatsu Y, Tanaka K, Sato M et al.. Intravenous methylprednisolone pulse therapy for Graves' ophthalmopathy.  Endocr J. 1993;  40 63-72
    PubMedGoogle Scholar
  • 39 Matejka G, Verges B, Vaillant G et al.. Intravenous methylprednisolone pulse therapy in the treatment of Graves' ophthalmopathy.  Horm Metab Res. 1998;  30 93-98
    Article in Thieme ConnectPubMedGoogle Scholar
  • 40 Ebner R, Devoto M H, Weil D et al.. Treatment of thyroid associated ophthalmopathy with periocular injections of triamcinolone.  Br J Ophthalmol. 2004;  88 1380-1386
    CrossrefPubMedGoogle Scholar
  • 41 Prummel M F, Mourits M P, Berghout A et al.. Prednisone and cyclosporine in the treatment of severe Graves' ophthalmopathy.  N Engl J Med. 1989;  321 1353-1359
    PubMedGoogle Scholar
  • 42 Leovey A, Bako G, Szabo J, Kalman K, Forizs E. Combined cyclosporin-A and methylprednisolone treatment of Graves' ophthalmopathy.  Acta Med Hung. 1992-93;  49 179-185
    PubMedGoogle Scholar
  • 43 Bartalena L, Marcocci C, Manetti L et al.. Orbital radiotherapy for Graves' ophthalmopathy.  Thyroid. 1998;  8 439-441
    PubMedGoogle Scholar
  • 44 Bartalena L, Marcocci C, Tanda M L et al.. Orbital radiotherapy for Graves' ophthalmopathy.  Thyroid. 2002;  12 245-250
    CrossrefPubMedGoogle Scholar
  • 45 Kahaly G J, Rosler H P, Pitz S et al.. Low- versus high-dose radiotherapy for Graves' ophthalmopathy: a randomized, single blind trial.  J Clin Endocrinol Metab. 2000;  85 102-108
    CrossrefPubMedGoogle Scholar
  • 46 Ohtsuka K, Sato A, Kawaguchi S, Hashimoto M, Suzuki Y. Effect of steroid pulse therapy with and without orbital radiotherapy on Graves' ophthalmopathy.  Am J Ophthalmol. 2003;  135 285-290
    CrossrefPubMedGoogle Scholar
  • 47 Gorman C A, Garrity J A, Fatourechi V et al.. A prospective, randomized, double-blind, placebo-controlled study of orbital radiotherapy for Graves' ophthalmopathy.  Ophthalmology. 2001;  108 1523-1534
    CrossrefPubMedGoogle Scholar
  • 48 Meyer D R. Orbital radiation therapy for Graves' ophthalmopathy.  Ophthalmology. 2003;  110 450-451 , author reply 451
    PubMedGoogle Scholar
  • 49 Wakelkamp I M, Tan H, Saeed P et al.. Orbital irradiation for Graves' ophthalmopathy: Is it safe? A long-term follow-up study.  Ophthalmology. 2004;  111 1557-1562
    CrossrefPubMedGoogle Scholar
  • 50 Graham S M, Brown C L, Carter K D et al.. Medial and lateral orbital wall surgery for balanced decompression in thyroid eye disease.  Laryngoscope. 2003;  113 1206-1209
    CrossrefPubMedGoogle Scholar
  • 51 Shepard K G, Levin P S, Terris D J. Balanced orbital decompression for Graves' ophthalmopathy.  Laryngoscope. 1998;  108(11 Pt 1) 1648-1653
    CrossrefPubMedGoogle Scholar
  • 52 Kalmann R, Mourits M P, van der Pol J P et al.. Coronal approach for rehabilitative orbital decompression in Graves' ophthalmopathy.  Br J Ophthalmol. 1997;  81 41-45
    PubMedGoogle Scholar
  • 53 Goldberg R A, Shorr N, Cohen M S. The medical orbital strut in the prevention of postdecompression dystopia in dysthyroid ophthalmopathy.  Ophthal Plast Reconstr Surg. 1992;  8 32-34
    PubMedGoogle Scholar
  • 54 Olivari N. Transpalpebral decompression of endocrine ophthalmopathy (Graves' disease) by removal of intraorbital fat: experience with 147 operations over 5 years.  Plast Reconstr Surg. 1991;  87 627-641 discussion 642-643
    CrossrefPubMedGoogle Scholar
  • 55 Liao S L, Shih M J, Lin L L. A procedure to minimize lower lid retraction during large inferior rectus recession in graves ophthalmopathy.  Am J Ophthalmol. 2006;  141 340-345
    CrossrefPubMedGoogle Scholar
  • 56 Elner V M, Hassan A S, Frueh B R. Graded full-thickness anterior blepharotomy for upper eyelid retraction.  Arch Ophthalmol. 2004;  122 55-60
    CrossrefPubMedGoogle Scholar
  • 57 Li T G, Shorr N, Goldberg R A. Comparison of the efficacy of hard palate grafts with acellular human dermis grafts in lower eyelid surgery.  Plast Reconstr Surg. 2005;  116 873-878
    CrossrefPubMedGoogle Scholar
  • 58 Gay A J, Wolkstein M A. Topical guanethidine therapy for endocrine lid retraction.  Arch Ophthalmol. 1966;  76 364-367
    PubMedGoogle Scholar

1 The authors have no conflicts of interest or proprietary interest in any of the instruments or topics presented in this manuscript.

Jeffrey A NeradM.D. 

Professor Director; Oculoplastic, Orbital and Oncology Service Department of Ophthalmology and Visual Sciences, University of Iowa Hospital and Clinics

200 Hawkins Drive, Iowa City, IA 52242-1091

      >