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Details About Graves

Graves' disease might present clinically with one of {the} following characteristic signs:

  • exophthalmos (protuberance of one or both eyes)
  • a non-pitting edema (pretibial myxedema), with thickening of {the} skin usually found on {the} lower extremities
  • fatigue, weight loss with increased appetite, and other symptoms of hyperthyroidism
  • rapid heart beats
  • muscular weakness
  • The two signs that are truly 'diagnostic' of Graves' disease (i.e., not seen in other hyperthyroid conditions) are exophthalmos and non-pitting edema (pretibial myxedema). Goiter is an enlarged thyroid gland and is of {the} diffuse type (i.e., spread throughout {the} gland). Diffuse goiter might be seen with other causes of hyperthyroidism, although Graves' disease is {the} most common cause of diffuse goiter. A large goiter will be visible to {the} naked eye, but a smaller goiter (very mild enlargement of {the} gland) might be detectable only by physical exam. Occasionally, goiter is not clinically detectable but might be seen only with CT or ultrasound examination of {the} thyroid.
  • Another sign of Graves' disease is hyperthyroidism, i.e., overproduction of {the} thyroid hormones T3 and T4. Normothyroidism is also seen, and occasionally also hypothyroidism, which might assist in causing goiter (though it is not {the} cause of {the} Graves disease). Hyperthyroidism in Graves' disease is confirmed, as with any other cause of hyperthyroidism, by measuring elevated blood levels of free (unbound) T3 and T4.
  • Other useful laboratory measurements in Graves' disease include thyroid-stimulating hormone (TSH, usually low in Graves' disease due to negative feedback from {the} elevated T3 and T4), and protein-bound iodine (elevated). Thyroid-stimulating antibodies might also be detected serologically.
  • Biopsy to obtain histiological testing is not normally required but might be obtained if thyroidectomy is performed.
  • Differentiating two common forms of hyperthyroidism such as Graves' disease and Toxic multinodular goiter is important to determine proper treatment. Measuring TSH-receptor antibodies with {the} h-TBII assay has been proven efficient and was {the} most practical approach found in one study.
Palpitations
Tachycardia (rapid heart rate: 100-120 beats per minute, or higher)
Arrhythmia (irregular heart beat)
Hypertension (Raised blood pressure)
Tremor (usually fine shaking, e.g., hands)
Hyperhidrosis (excessive sweating)
Heat intolerance
Polyphagia (increased appetite)
Unexplained weight loss despite increased appetite
Dyspnea (shortness of breath)
Muscle weakness (especially in {the} large muscles of {the} arms and legs) and degeneration
Insomnia (inability to get enough sleep
 Diminished/changed sex drive
Insomnia (inability to get enough sleep) Palpitations
Tachycardia (rapid heart rate: 100-120 beats per minute, or higher)
Arrhythmia (irregular heart beat)
Hypertension (Raised blood pressure)
Tremor (usually fine shaking, e.g., hands)
Hyperhidrosis (excessive sweating)
Heat intolerance
Polyphagia (increased appetite)
Unexplained weight loss despite increased appetite
Dyspnea (shortness of breath)
Muscle weakness (especially in {the} large muscles of {the} arms and legs) and degeneration
Diminished/changed sex drive
   
Increased energy
Fatigue
Mental impairment, memory lapses, diminished attention span
Decreased concentration
Nervousness, agitation
Irritability
Restlessness
Erratic behavior
Emotional lability
Brittle nails
Abnormal breast enlargement
Goiter (enlarged thyroid gland)
Diplopia (double vision)
Eye pain, irritation, tingling sensation behind {the} eyes or {the} feeling of grit or sand in {the} eyes
Swelling or redness of eyes or eyelids/eyelid retraction
Sensitivity to light
Decrease in menstrual periods (oligomenorrhea), irregular and scant menstrual flow (amenorrhea)
Difficulty conceiving/infertility/recurrent miscarriage
Chronic sinus infections
Lumpy, reddish skin of {the} lower legs (pretibial myxedema)
Increased bowel movements or diarrhea
Panic attacks
Protruding eyeballs
   

Eye disease

  • Thyroid-associated ophthalmopathy is one of {the} most typical symptoms of Graves' disease. It is known by a variety of terms, {the} most common being Graves' ophthalmopathy. Thyroid eye disease is an inflammatory condition, which affects {the} orbital contents including {the} extraocular muscles and orbital fat. It is almost always associated with Graves' disease but might rarely be seen in Hashimoto's thyroiditis, primary hypothyroidism, or thyroid cancer.

 

  • The ocular manifestations that are relatively specific to Grave's disease include soft tissue inflammation, proptosis (protrusion of one or both globes of {the} eyes), corneal exposure, and optic nerve compression. Also seen, if {the} patient is hyperthyroid, (i.e., has too much thryoid hormone) are more general manifestations, which are due to hyperthyroidism itself and which might be seen in any conditions that cause hyperthyroidism (such as toxic multinodular goiter or even thyroid poisoning). These more general symptoms include lid retraction, lid lag, and a delay in {the} downward excursion of {the} upper eyelid, during downward gaze.
  • It is believed that fibroblasts in {the} orbital tissues might express {the} Thyroid Stimulating Hormone receptor (TSHr). This might explain why one autoantibody to {the} TSHr can cause disease in both {the} thyroid and {the} eyes

Lid Retraction
Photo of a patient with Graves' disease

Proptosis



 

Graves Disease

 

Graves Disease

  • Grave's Ophthalmolopathy is {the} most common caused of unilateral or bilateral proptosis in adults.
  • It commonly occurs between {the} ages of 25-50, although it might also present in adolescents.
  • Diagnosis is made based on clinical findings including proptosis, eyelid retraction, restrictive myopathy and possibly compressive optic neuropathy. It is often grouped into two independent manifestations of this syndrome:
  • Type I and Type II orbitapathy, but might overlap

More frequent signs:

Less frequent signs:
  • lid lag (upper and lower)
  • exophthalmos
  • diplopia
  • lid edema
  • chemosis
  • conj injection over recti
  • increased IOP with elevation
  • keratopathy
  • closed lid tremor
  • infrequent blinking
  • difficult eversion upper lid
  • bruit over eye
  • decrease forehead wrinkling with upgaze
  • increased hippus
  • pigmented lids
  • Werner's Classification

    NO SPECS, with each class in four grades 0-4, a, b, c: mild to severe

    • 0 No S/S
    • 1 Only signs (lid retraction)
    • 2 Soft tissue involved (chemosis, grit, etc)
    • 3 Proptosis (min 28)
    • 4 EOM involved
    • 5 Corneal involvement
    • 6 Sight loss
Symptom Type I Type II
Sex predilection Female  
Proptosis Symmetric Unilateral or bilateral
Eyelid retraction Symmetric Unilateral or bilateral
Orbital inflammation Minimal  
Extraocular muscle inflammation/ restriction Minimal Frequent
Chemosis Unusual Usual
diplopia Unusual Frequent
Compressive optic neuropathy Unusual Frequent

 

  • Diagnosis is made on these clinical findings and might be confirmed on CT which shows enlargement of multiple extraocular muscles most commonly {the} inferior and medial rectus.
  • Systemic thyroid might be hyperthyroid, hypothyroid, or euthyroid. Treatment might include topical lubrication, systemic steroids, orbital decompression surgery, extraocular muscle adjustment, eyelid recession surgery and radiation therapy.