Signs of endocrine ophthalmopathy and methods of treating exophthalmos. Endocrine ophthalmopathy, common when hormone production is disrupted: treatment of an unpleasant symptom and eye damage Ophthalmopathy after removal of the thyroid gland
Among the many autoimmune diseases, endocrine ophthalmopathy is considered one of the most studied and long known. Nevertheless, its manifestations still interfere with the full life of many people, and much more serious problems are hidden behind external, cosmetic disorders. What is the danger of this condition?
What is endocrine ophthalmopathy
Endocrine ophthalmopathy is an autoimmune condition that originates in the thyroid tissue and affects the visual system. In most cases, it is accompanied by protrusion of the eyeball (exophthalmos) and paralysis of local muscles (ophthalmoplegia).
Endocrine ophthalmopathy is called autoimmune, thyroid, and Graves' ophthalmopathy, named after the Irish surgeon Robert James Graves, who first described it in 1835.
Endocrine ophthalmopathy is a common condition, diagnosed in approximately 2% of the world's population. Women, who are more prone to thyroid disease, suffer from it 6-8 times more often than men. The first manifestations can occur at any age, but peak incidence rates occur in the second, fifth and seventh decades of life. The severity of symptoms increases significantly over the years.
Video: endocrine ophthalmopathy
Causes
The mechanism of endocrine ophthalmopathy is a stepwise process, the first stage of which is a malfunction of the thyroid gland. Most often we are talking about diseases:
- thyrotoxicosis;
- autoimmune thyroiditis;
- euthyroidism.
In addition, the body's reaction can be initiated by external factors:
- infectious agents:
- influenza virus;
- gonococci;
- streptococci;
- retroviruses;
- irradiation:
- gamma radiation;
- ultraviolet;
- poisoning:
- alcohol;
- components of tobacco smoke;
- salts of heavy metals;
- carbon monoxide;
- regular stress;
- violation of the integrity of thyroid tissue:
- traumatic;
- surgical - as a result of incomplete removal of the organ.
Proteins from the tissues of the gland, freely entering the blood, are perceived by the body as foreign and cause an immune response. Their presence on cell membranes is a selection criterion. As a result, not only thyroid tissues are destroyed, but also everything similar to them in surface properties. The latter includes retrobulbar tissue - fat cells located in the orbit.
Damage to retrobulbar tissues leads to swelling and, over time, to scarring. The work of the adjacent muscles is disrupted, and the pressure in the orbit increases irreversibly. The consequence of these changes are typical symptoms of the disease.
An autoimmune process that begins in fatty tissue leads to nerve and muscle damage
Symptoms of the disease
The autoimmune process can precede obvious damage to the thyroid gland, occur immediately after it, or be delayed for a long time - up to 10–15 years. The first symptoms of Graves' ophthalmopathy are subtle and are usually perceived as signs of eye fatigue. These include:
- disruption of the lacrimal glands:
- lacrimation;
- dryness;
- swelling around the eyes;
- pain;
- photophobia.
Over time, exophthalmos begins to develop, the severity of which increases as the disease progresses.
Exophthalmos is a typical symptom of Graves' ophthalmopathy Table: stages of endocrine ophthalmopathy
| External manifestations | Stage | ||
| 1 | 2 | 3 | |
| Bulging of the eyeball (exophthalmos) | Up to 15.9 mm | About 17.9mm | 20.9 mm or more |
| Swelling of the eyelids (Gifferd-Enors sign) | Moderate | Strong | Very strong |
| Difficulty blinking (Stellwag's sign) | Blinking is accompanied by mild discomfort | Blinking is very difficult | Inability to completely close the eyelids |
| Eyelids wide apart, pulled up (Dalrymple's sign) | Signs are not expressed | Mild or moderate symptoms | Strong manifestations |
| When looking down, the sclera clearly appears above the iris, the upper eyelid is raised (Kocher's sign) | |||
| Trembling eyelids (Rodenbach's sign) | |||
| Eyelids bend when closed (Pokhin syndrome) | |||
| The eyelids become brown (Jellinek's sign) | Changes are not noticeable | Distinct pigmentation | Strong pigmentation |
| Eye movements are not coordinated (Möbius-Graefe-Means sign) | Not expressed | Periodic manifestations expressed in mild double vision | Persistent manifestations, constant ghosting |
| Condition of the conjunctiva | Not affected | Edema | Inflamed |
| Cornea condition | Not affected | There is dryness due to the inability to close the eyelids | Ulcerated |
| Condition of the optic nerve | Not affected | Compresses, sometimes atrophies | |
Depending on the initial causes of the disease, the set and intensity of symptoms may vary, and the course of ophthalmopathy occurs in one of three forms:
- thyrotoxic exophthalmos:
- often occurs during the treatment of thyroid diseases;
- accompanied by systemic manifestations:
- insomnia;
- shaking (tremor) of hands;
- irritability;
- rapid heartbeat;
- feeling of heat;
- provokes disturbances in eyelid movements:
- trembling when closing;
- decreased blinking frequency;
- widening of the palpebral fissures;
- has little effect on the structure and functioning of the eye;
- edematous exophthalmos:
- accompanied by severe tissue changes:
- swelling;
- muscle paralysis;
- dilation of blood vessels supplying the external eye muscles;
- venous stagnation;
- displacement of the eyeballs (up to 3 cm);
- atrophy;
- changes the motor activity of the upper eyelids:
- retraction (lifting) increases;
- after sleep, partial prolapse is observed;
- when closing, a tremor occurs.
- accompanied by severe tissue changes:
- endocrine myopathy:
- affects both eyes;
- predominantly affects muscle tissue, causing:
- thickening of fibers;
- compaction;
- weakness;
- collagen degeneration;
- develops gradually.
Paralysis of the eye muscles is the main cause of diplopia (double vision) Diagnostics
An external examination of a patient suffering from endocrine ophthalmopathy allows not only to make a preliminary diagnosis based on typical manifestations, but also to assess the activity of the disease. An ophthalmologist determines the presence of the following symptoms:
- Pain when moving the eyes up or down.
- Unreasonable pain behind the eyeball.
- Swelling of the eyelids.
- Redness of the eyelids.
- Swelling of the semilunar fold and lacrimal caruncle.
- Redness of the conjunctiva.
- Swelling of the conjunctiva (chemosis).
- Increased exophthalmos - over 2 mm in 2 months.
- Decreased eye mobility - over 8% in 2 months.
- Weakening of vision - by more than 0.1 acuity in 2 months.
These criteria make up the Clinical Activity Score, or CAS. Signs from 1 to 7 are considered basic, and from 8 to 10 - additional. The former are identified upon diagnosis; to determine the latter, repeated examination is required. Each confirmed symptom adds one point to the total score. If it is less than two points, endocrine ophthalmopathy is inactive. CAS over three indicates the active development of the disease.
Using an exophthalmometer, the displacement of the eyeball is determined An external ophthalmological examination is usually supplemented by instrumental studies necessary for an accurate assessment of the changes that have occurred in the tissues:
- biomicroscopy - to study the condition of eye tissues;
- visometry - to determine visual acuity;
- measurement:
- convergence (information of visual axes);
- angle;
- ophthalmoscopy - examination of the fundus of the eye;
- perimetry - assessment of visual fields;
- exophthalmometry - determining the displacement of the eyeballs;
- tonometry - measuring intraocular pressure;
- tomography:
- computer (CT);
- magnetic resonance imaging (MRI);
- ultrasound diagnostics (ultrasound).
Non-invasive imaging methods (ultrasound, MRI, CT) can determine thickening of the eye muscles, swelling of the lacrimal glands, manifestations of fibrosis, as well as other signs indicating the progression of the pathology.
Tomographic studies allow you to quickly detect abnormalities in the eye tissues In addition to ophthalmological examinations, laboratory tests are of great importance. They accurately indicate the cause of the disease, assess the degree of damage to the thyroid gland, the intensity of the autoimmune process, and hidden complications. Such studies include:
- blood test:
- for hormones:
- triiodothyronine (T3);
- thyroxine (T4);
- thyroid stimulating hormone (TSH);
- for antibodies to the body's own proteins:
- acetylcholinesterase;
- thyroglobulin;
- thyroid peroxidase;
- a second colloidal antigen;
- eye muscle protein AMAb;
- on the number of T-lymphocytes:
- CD3+ cells;
- CD8+ cells;
- for hormones:
- biopsy:
- eye muscles;
- thyroid tissue.
Performing diagnostic tests makes it possible to accurately differentiate cases of endocrine ophthalmopathy with similar diseases and determine an effective treatment strategy.
Table: differential diagnosis of Graves' ophthalmopathy
| Disease | Differences from Graves' ophthalmopathy | Diagnostic methods |
| Myopia (severe) |
| External examination, blood test, MRI, CT, ultrasound |
| Myasthenia gravis |
|
|
| Optic neuropathy |
|
|
| Orbital tumors | Changed cells are present in the tissues of the eye | Biopsy, blood test |
| Cellulitis of the orbit |
| External examination, blood test, CT, MRI, biopsy, microscopy |
Treatment
Considering the autoimmune origin of endocrine ophthalmopathy and the severity of tissue changes, all therapeutic measures must certainly be carried out under the supervision of specialists - an ophthalmologist and an endocrinologist. Self-medication without an accurate diagnosis is not only useless, but can also cause severe harm to the patient’s health.
Conservative treatment
The main method of suppressing autoimmune processes in Graves' ophthalmopathy is glucocorticoid therapy (Dexamethasone, Diprospan, Kenacort, Metipred, Prednisolone), used in the form of tablets or injection solutions. Administration of drugs can be done either intravenously or retrobulbarly.
Small doses of glucocorticoids for endocrine ophthalmopathy do not have the proper therapeutic effect, so their daily amount should be 40–80 mg in terms of prednisolone, followed by a gradual decrease. Particularly effective is pulse therapy with methylprednisolone, which involves the administration of large doses of the drug (0.5–1 g) over a short period of time (up to 5 days). This method of administration, in addition to a strong targeted effect, is accompanied by fewer side effects.
However, glucocorticoid therapy should be avoided if the following conditions are present:
- arterial hypertension;
- malignant tumors;
- mental illness;
- thrombophlebitis;
- peptic ulcer.
Disturbed functions of the thyroid gland require correction:
- thyroid hormones (Levothyroxine, Euthyrox) – for hypothyroidism;
- thyreostatics (Mercazolil, Thiamazol) – for hyperthyroidism.
Taking diuretics (Veroshpiron, Diakarb, Furosemide) helps reduce swelling. To restore muscle activity, Prozerin and its analogues (Kalimin, Physostigmine) are used. Metabolism stimulants (Actovegin), vitamins A and E are also used for this purpose.
Photo gallery: medications used in the treatment of Graves' ophthalmopathy
Veroshpiron helps reduce swelling 
Actovegin stimulates tissue regeneration 
Levothyroxine is used to correct thyroid function 
Metypred and its analogues suppress the autoimmune process 
Prozerin accelerates the recovery of eye muscles
Targeted irradiation of the eye orbits with low doses of radiation can suppress local autoimmune reactions. The main disadvantage of this method is the high risk of complications, which is about 12%. Safe ways to cleanse the body of autoimmune cells and proteins are:
- hemosorption - removal of particles from the blood using a sorbent;
- immunosorption - purification using specific antibodies;
- cryapheresis - deposition of particles at low temperatures;
- plasmapheresis - removal of part of the plasma with the proteins it contains.
Surgical intervention
- diplopia (double vision);
- significant swelling of the eyelids and lacrimal glands;
- tissue ulceration;
- irreversible eyelid retraction;
- proliferation of retrobulbar tissue;
- compression of the optic nerve;
- severe exophthalmos (2–3 cm).
Surgical treatment should be started only if medication has shown to be ineffective. Active inflammation is a serious contraindication for surgery, therefore, if there is a choice, it is better to delay the intervention until it subsides. The choice of treatment method depends entirely on the symptoms.
Severe cases of Graves' ophthalmopathy require surgery About 5% of cases of Graves' othalmopathy require surgery.
Table: methods of surgical intervention for endocrine ophthalmopathy
| Type of manipulation | Indications for implementation | Types of operations |
| Relieving pressure in the eye orbit (decompression) |
|
|
| Manipulation of the eye muscles |
|
|
| Eyelid manipulation (blepharoplasty) |
|
|
| Thyroid surgery | Hormonal disorders that cannot be corrected with medication | Thyroidectomy (removal of the gland). |
Surgeries on the eyelids are performed under local anesthesia, using a 2% solution of novocaine or lidocaine. Other types of intervention involve the use of general anesthesia. Correcting muscle defects may require a series of several operations, with mandatory ophthalmological examination after each.
Eyelid surgery requires the use of local anesthesia Use of folk remedies
The autoimmune origin of Graves' ophthalmopathy makes it insensitive to the use of traditional medicine. Such therapy can be used only to get rid of symptoms, and only in the initial stages of the disease. However, even symptomatic treatment should be used after consultation with your doctor. Herbal components, if used incorrectly, can enhance the immune response, thereby complicating the course of ophthalmopathy.
Parsley has a strong diuretic effect that helps reduce swelling. The simplest infusion can be obtained from it by pouring 100 g of fresh leaves with half a liter of boiling water. After fifteen minutes of infusion and straining, the product can be used both for compresses and for oral administration - 1 glass 2-3 times a day, an hour after meals.
Herbal mixture with parsley is more effective. To obtain it you need:
- Mix 20 g of dried leaves of cassia angustifolia, parsley, dandelion, nettle, 10 g each of peppermint and dill.
- 1 tsp. pour a glass of boiling water over the mixture.
- Leave for 15–20 minutes. Strain.
- Drink 1 glass of fresh infusion 3 times a day after meals for a month.
An infusion of crushed chokeberry berries (2 tsp), infused in a glass of boiling water for half an hour, also promotes the outflow of fluid from tissues. This remedy should be taken twice a day, 3 tbsp. l., an hour before meals. A mixture prepared as follows also has a strong diuretic and decongestant effect:
- Carefully chop 1 kg of onions.
- Add 10 walnuts, 150 g of honey, 150 ml of vodka to the resulting pulp of the partition.
- Mix thoroughly. Leave for 10 days in a dark place.
- Take 1 tbsp. l. three times a day, an hour before meals.
Excessive tension in the eye muscles can be relieved by sage infusion. 100 g of dry herb should be poured with 200 ml of boiling water and left for 8 hours in a warm, dark place. The product should be taken 1 tsp. 2-3 times a day, an hour after meals. After each use you need to drink a small amount of milk.
Photo gallery: herbal components used for symptomatic treatment
Chokeberry relieves swelling 
Walnut septa help remove excess fluid 
Parsley has a strong anti-edematous effect 
Sage can relieve muscle tension
Treatment prognosis
With early diagnosis of Graves' ophthalmopathy and correctly prescribed therapy, the treatment prognosis is quite favorable. Further progress of the disease is associated with changes in the tissues of the orbit, which reduces the likelihood of a favorable outcome. On average, after a course of treatment, 60% of patients experience stabilization of their condition, and 30% have a noticeable improvement.
Inaccurate diagnosis or untimely therapy can provoke an intensification of the pathological process, ultimately leading to complications:
- relapses of ophthalmopathy;
- persistent diplopia;
- sinusitis;
- loss of sensation in the area around the eyes;
- strabismus;
- eye bleeding and hemorrhage;
- blindness.
Prevention
The best measure to prevent Graves' ophthalmopathy is regular examination by an ophthalmologist and endocrinologist. Their prescriptions will help prevent thyroid pathologies, and if they develop, identify the disease at an early stage.
- stop smoking;
- do not allow the cornea to dry out by using artificial tear drops;
- Protect your eyes from direct sunlight.
Endocrine ophthalmopathy- a disease of the retrobulbar tissues and muscles of the eyeball of an autoimmune nature, which occurs against the background of thyroid pathology and leads to the development of exophthalmos, or bulging eyes, and a complex of eye symptoms. This disease was first described by R.J. Graves in 1835. That is why some authors call the pathology Graves' ophthalmopathy. Until recently, it was believed that endocrine ophthalmopathy was a symptom of an autoimmune disease of the thyroid gland - diffuse toxic goiter. Currently, endocrine ophthalmopathy is considered an independent disease.
Both endocrinologists and ophthalmologists study and treat patients with this pathology. According to medical statistics, the disease affects about 2% of the total population, and women suffer from it 6-8 times more often than men. Endocrine ophthalmopathy most often manifests itself in two age periods - 40-45 and 60-65 years. In addition, the literature describes cases of this disease occurring in childhood in girls aged 5-15 years. In 80% of cases, Graves' ophthalmopathy accompanies diseases that cause disturbances in the hormonal function of the thyroid gland, and only in a quarter of cases occurs against the background of euthyroidism - a state of normal functioning of the thyroid gland.
Causes and mechanisms of development of endocrine ophthalmopathy
In 90-95% of cases, endocrine ophthalmopathy develops against the background of diffuse toxic goiter. Moreover, eye damage can be observed both at the height of the underlying disease and 10-15 years after its treatment, and sometimes long before it.
Endocrine ophthalmopathy is based on damage to the soft tissues of the orbit, associated with dysfunction of the thyroid gland of varying degrees of severity. The reasons that trigger the development of endocrine ophthalmopathy have not yet been clarified. The triggering factors of pathology are considered to be retroviral or bacterial infections, exposure to toxins, smoking, radiation, insolation and stress on the body.
The autoimmune nature of the disease is confirmed by the mechanism of its development, in which the patient’s immune system perceives the fiber surrounding the eyeball as a carrier of thyroid-stimulating hormone receptors, as a result of which it begins to synthesize antibodies against them (antibodies to the TSH receptor, abbreviated as AT to rTSH). Having penetrated the tissue of the orbit, antibodies cause immune inflammation, accompanied by infiltration. At the same time, fiber begins to actively produce substances that attract fluid - glycosaminoglycans.
The result of this process is swelling of the eye tissue and an increase in the volume of the extraocular muscles, which create pressure in the bony base of the orbit, which further causes specific symptoms of the disease (primarily exophthalmos, protrusion of the eyeball anteriorly with the appearance of the symptom of “bulging eyes”). Over time, the inflammatory process subsides, and the infiltrate degenerates into connective tissue, i.e. a scar is formed, after the formation of which exophthalmos becomes irreversible.
Endocrine ophthalmopathy - classification
There are several types of classifications of endocrine ophthalmopathy. In domestic medicine, the most common classification is according to V.G. Baranova, according to which they distinguish degree of endocrine ophthalmopathy accompanied by certain clinical manifestations.
- 1st degree characterized by slight bulging eyes (up to 16 mm), moderate swelling of the eyelids, without dysfunction of the extraocular muscles and conjunctiva;
- 2nd degree accompanied by moderately severe exophthalmos (up to 18 mm), significant swelling of the upper and lower eyelids, as well as the conjunctiva, and periodic double vision;
- 3rd degree. It is characterized by severe exophthalmos (up to 21 mm), the inability to completely close the eyelids, erosions and ulcers on the cornea, limited mobility of the eyeball and signs of optic nerve atrophy.
Also in practice, the classification of endocrine ophthalmopathy by A.F. is often used. Brovkina, based on the severity of ocular symptoms, and including three main forms diseases: thyrotoxic exophthalmos, edematous exophthalmos and endocrine myopathy.
Symptoms of endocrine ophthalmopathy
Thyrotoxic exophthalmos manifests itself clinically in the form of slight true or false protrusion of the eyeballs, retraction of the upper eyelid, due to which there is a widening of the palpebral fissure, slight trembling of the closed eyelids and insufficient convergence. No morphological changes are detected in the retrobulbar tissues. The range of movements of the periocular muscles is not limited, the fundus of the eye is unchanged.
For edematous exophthalmos Characteristic is bilateral damage to the eyeballs, occurring more often at different time periods, with an interval of up to several months. During this form of endocrine ophthalmopathy, three stages are distinguished.
1. Compensation stage. The onset of the disease is characterized by a number of specific symptoms, namely, in the morning there is a slight drooping of the upper eyelid, which disappears in the evening. The palpebral fissure closes completely. Over time, partial drooping of the eyelid is transformed into persistent retraction (contraction) due to spasm and prolonged increased muscle tone, which leads to contracture of the Müller muscle and superior rectus muscle of the eye.
2. Subcompensatory stage. The outer canthus and the area along the lower eyelid are affected by white chemosis, intraocular pressure increases and swelling of the periocular tissues of a non-inflammatory nature develops. Bulging eyes grows very quickly, the palpebral fissure ceases to close completely. The vessels of the sclera expand, become convoluted and form a figure resembling a cross. It is this symptom that gives rise to the diagnosis of edematous exophthalmos. When the eyeballs move, an increase in intraocular pressure is observed.
3. Decompensatory stage. Characterized by a sharp increase in symptoms. A large degree of bulging eyes develops, the palpebral fissure does not close at all due to swelling of the eyelids and periocular tissue. The eye is immobilized. The development of optic neuropathy is observed, turning into atrophy of the optic nerve. Due to compression of the ciliary nerves, keratopathy and erosive and ulcerative lesions of the cornea develop. If the necessary treatment is not carried out, this stage of edematous exophthalmos ends with fibrosis of the orbital tissue and a sharp deterioration in vision due to corneal cataract or optic nerve atrophy.
Endocrine myopathy most often affects both eyes, usually occurs in men against the background of a hypothyroid or euthyroid state. The onset of the pathological process is manifested by double vision, the intensity of which tends to increase. Then exophthalmos joins. Swelling of the periocular tissue is not observed in this form of endocrine ophthalmopathy, but the rectus oculomotor muscles thicken, which leads to disruption of their function and limitation in the abduction of the eyes outward, downward and upward. The infiltrative stage of this form of endocrine ophthalmopathy is very short-lived, and tissue fibrosis is observed after just a few months.
Protruding eyes in Graves' ophthalmopathy must be differentiated from false protruding eyes, which can occur with inflammatory processes in the orbit, tumors, and a significant degree of myopia.
How is endocrine ophthalmopathy diagnosed?
The diagnosis of “endocrine ophthalmopathy” is made on the basis of a set of instrumental and laboratory research methods carried out by an endocrinologist and an ophthalmologist.
Endocrinological examination involves determining the level of thyroid hormones, identifying antibodies to gland tissues, and ultrasound examination of the thyroid gland. If ultrasound reveals nodes more than 1 cm in diameter in the structure of the gland, a puncture biopsy is indicated.
Examination by an ophthalmologist consists of viziometry, perimetry, convergence studies. It is necessary to conduct an examination of the fundus of the eye - ophthalmoscopy, determination of the level of intraocular pressure - tonometry. If it is necessary to clarify the diagnosis, MRI, CT, ultrasound of the orbit and biopsy of the extraocular muscles can be performed.
Treatment of endocrine ophthalmopathy
Options for therapeutic measures aimed at correcting endocrine ophthalmopathy are determined depending on the degree of dysfunction of the thyroid gland, the form of the disease and the reversibility of pathological changes. A prerequisite for successful treatment is the achievement of a euthyroid state (normal levels of hormones T4 free, T3 free, TSH).
The main goals of treatment are hydration of the conjunctiva, prevention of the development of keratopathy, correction of intraocular pressure, suppression of destruction processes inside the eyeball and preservation of vision.
Since the process develops against the background of an underlying autoimmune lesion of the thyroid gland, it is recommended to use drugs that suppress the immune response - glucocorticoids, corticosteroids. Contraindications to the use of these drugs may include pancreatitis, gastric ulcers, thrombophlebitis, tumor processes and mental illness. In addition, plasmapheresis, hemosorption, and cryoapheresis are used.
Indicators for hospitalization of a patient include such signs as a sharp limitation of the movement of the eyeballs, diplopia, a corneal ulcer, rapidly progressing bulging eyes, and suspicion of optic neuropathy.
Mandatory correction of thyroid function thyrostatics or hormones. If there is no effect from the use of drugs, they resort to thyroidectomy - removal of the thyroid gland, followed by hormone replacement therapy. Currently, the opinion is becoming increasingly widespread that the thyroid gland must be completely removed at the first symptoms of ophthalmopathy, since after removal of the thyroid tissue in the blood, the titer of antibodies to the TSH receptor decreases significantly. A decrease in antibody titer improves the course of ophthalmopathy and increases the likelihood of a significant regression of its symptoms. The earlier thyroidectomy is performed, the more pronounced the improvement in eye condition is.
As symptomatic treatment endocrine ophthalmopathy, drugs are prescribed that normalize metabolic processes in tissues - actovegin, proserin, vitamins A and E, antibacterial drops, artificial tears, ointments and gels for moisturizing. The use of physiotherapeutic methods of treatment is also recommended - electrophoresis with aloe, magnetic therapy on the eye area.
Surgical treatment endocrine ophthalmopathy includes three types of operations - relieving tension in the orbit, operations on the muscular system of the eyes and eyelids. The choice in favor of one type of surgical intervention or another depends on the symptoms of the pathological process. Orbital decompression, for example, is indicated for optic neuropathy, severe bulging eyes, ulcerative lesions of the cornea and subluxation of the eyeball. With its help, an increase in the volume of the orbit is achieved by removing one or more orbital walls and excision of the periocular tissue.
Oculomotor muscles are subjected to surgical treatment for persistent double vision and strabismus, if they are not corrected conservatively. Eyelid surgery consists of a group of plastic and functional operations, the selection of which is carried out based on the form of the developed disorder (drooping, swelling of the eyelids, retraction, etc.).
Prognosis of endocrine ophthalmopathy
The prognosis of endocrine ophthalmopathy depends on the timeliness of treatment. If the disease is diagnosed in the early stages and the correct treatment plan is developed, long-term remission of the disease can be achieved and severe irreversible consequences can be prevented. According to statistics, a third of patients experience clinical improvement, and two thirds experience stabilization of the process. In 5%-10% of cases, further progression of endocrine ophthalmopathy is possible.
After treatment, ophthalmological monitoring is required after six months, as well as constant monitoring and correction of thyroid function by an endocrinologist. Patients with Graves' ophthalmopathy should be registered at the dispensary.
Basedow's disease (Graves' disease, diffuse toxic goiter)
The cause of Graves' disease lies in the improper functioning of the human immune system, which begins to produce special antibodies - TSH receptor antibodies - directed against the patient's own thyroid gland
Thyroid hormone test
A blood test for thyroid hormones is one of the most important in the practice of the North-Western Endocrinology Center. In the article you will find all the information that patients who are planning to donate blood for thyroid hormones need to know
Thyroid surgery
The North-Western Center for Endocrinology is the leading institution of endocrine surgery in Russia. Currently, the center annually performs more than 5,000 operations on the thyroid gland, parathyroid glands, and adrenal glands. In terms of the number of operations, the North-Western Center for Endocrinology consistently ranks first in Russia and is one of the three leading European endocrine surgery clinics
Consultation with an endocrinologist
Specialists at the Northwestern Endocrinology Center diagnose and treat diseases of the endocrine system. The center's endocrinologists base their work on the recommendations of the European Association of Endocrinologists and the American Association of Clinical Endocrinologists. Modern diagnostic and treatment technologies ensure optimal treatment results.
Expert ultrasound of the thyroid gland
Ultrasound of the thyroid gland is the main method for assessing the structure of this organ. Due to its superficial location, the thyroid gland is easily accessible for ultrasound. Modern ultrasound machines allow you to examine all parts of the thyroid gland, with the exception of those located behind the sternum or trachea.
is an organ-specific progressive lesion of the soft tissues of the orbit and eye, developing against the background of autoimmune pathology of the thyroid gland. The course of endocrine ophthalmopathy is characterized by exophthalmos, diplopia, swelling and inflammation of the eye tissues, limited mobility of the eyeballs, changes in the cornea, optic disc disc, and intraocular hypertension. Diagnosis of endocrine ophthalmopathy requires an ophthalmological examination (exophthalmometry, biomicroscopy, orbital CT); studies of the state of the immune system (determination of the level of Ig, Ab to TG, Ab to TPO, antinuclear antibodies, etc.), endocrinological examination (T4 light, T3 light, ultrasound of the thyroid gland, puncture biopsy). Treatment of endocrine ophthalmopathy is aimed at achieving a euthyroid state; may include drug therapy or removal of the thyroid gland.
ICD-10
H57.9 E05.0
General information
Endocrine ophthalmopathy (thyroid ophthalmopathy, Graves' ophthalmopathy, autoimmune ophthalmopathy) is an autoimmune process that occurs with specific damage to retrobulbar tissues and is accompanied by exophthalmos and ophthalmoplegia of varying severity. The disease was first described in detail by K. Graves in 1776.
Endocrine ophthalmopathy is a problem of clinical interest in endocrinology and ophthalmology. Endocrine ophthalmopathy affects approximately 2% of the total population, while among women the disease develops 5-8 times more often than among men. Age dynamics are characterized by two peaks of manifestation of Graves' ophthalmopathy - at 40-45 years and 60-65 years. Endocrine ophthalmopathy can also develop in childhood, more often in girls in the first and second decades of life.
Reasons
Endocrine ophthalmopathy occurs against the background of primary autoimmune processes in the thyroid gland. Ocular symptoms may appear simultaneously with the clinical manifestations of thyroid disease, precede it, or develop in the long term (on average, after 3-8 years). Endocrine ophthalmopathy can be accompanied by thyrotoxicosis (60-90%), hypothyroidism (0.8-15%), autoimmune thyroiditis (3.3%), euthyroid status (5.8-25%).
The factors that initiate endocrine ophthalmopathy have not yet been fully elucidated. The following can act as triggers:
- respiratory infections,
- low doses of radiation,
- insolation,
- smoking,
- heavy metal salts,
- stress,
- autoimmune diseases (diabetes mellitus, etc.), causing a specific immune response.
An association of endocrine ophthalmopathy with some antigens of the HLA system has been noted: HLA-DR3, HLA-DR4, HLA-B8. Mild forms of endocrine ophthalmopathy are more common among young people, severe forms of the disease are typical for older people.
Pathogenesis
It is assumed that due to spontaneous mutation, T lymphocytes begin to interact with membrane receptors of eye muscle cells and cause specific changes in them. The autoimmune response of T lymphocytes and target cells is accompanied by the release of cytokines (interleukin, tumor necrosis factor, γ-interferon, transforming growth factor b, platelet-derived growth factor, insulin-like growth factor 1), which induce fibroblast proliferation, collagen formation and glycosaminoglycan production. The latter, in turn, contribute to the binding of water, the development of edema and an increase in the volume of retrobulbar fiber. Swelling and infiltration of orbital tissues are eventually replaced by fibrosis, as a result of which exophthalmos becomes irreversible.
Classification
In the development of endocrine ophthalmopathy, a phase of inflammatory exudation and an infiltration phase are distinguished, which is replaced by a phase of proliferation and fibrosis. Taking into account the severity of eye symptoms, three forms of endocrine ophthalmopathy are distinguished:
- Thyrotoxic phthalmos. It is characterized by slight true or false protrusion of the eyeballs, retraction of the upper eyelid, lag of the eyelid when lowering the eyes, tremor of the closed eyelids, glare of the eyes, convergence insufficiency.
- Edema exophthalmos. Edema exophthalmos is indicated when the eyeballs protrude by 25–30 mm, pronounced bilateral edema of the periorbital tissues, diplopia, and severely limited mobility of the eyeballs. Further progression of endocrine ophthalmopathy is accompanied by complete ophthalmoplegia, non-closure of the palpebral fissures, conjunctival chemosis, corneal ulcers, congestion in the fundus, pain in the orbit, and venous stasis. In the clinical course of edematous exophthalmos, the phases of compensation, subcompensation and decompensation are distinguished.
- Endocrine myopathy. With endocrine myopathy, weakness often occurs in the rectus oculomotor muscles, leading to diplopia, the inability to move the eyes outward and upward, strabismus, and downward deviation of the eyeball. Due to hypertrophy of the extraocular muscles, their collagen degeneration progressively increases.
To indicate the severity of endocrine ophthalmopathy in Russia, V. G. Baranov’s classification is usually used, according to which there are 3 degrees of endocrine ophthalmopathy.
- The criteria for endocrine ophthalmopathy of the 1st degree are: mild exophthalmos (15.9 mm), moderate swelling of the eyelids. The tissues of the conjunctiva are intact, the function of the extraocular muscles is not impaired.
- Endocrine ophthalmopathy of the 2nd degree is characterized by moderately severe exophthalmos (17.9 mm), significant swelling of the eyelids, severe swelling of the conjunctiva, and periodic double vision.
- With endocrine ophthalmopathy of the 3rd degree, pronounced signs of exophthalmos (20.8 mm or more), persistent diplopia, inability to completely close the eyelids, corneal ulceration, and optic nerve atrophy are detected.
Symptoms of endocrine ophthalmopathy
Early clinical manifestations of endocrine ophthalmopathy include transient sensations of “sand” and pressure in the eyes, lacrimation or dry eyes, photophobia, and swelling of the periorbital area. Subsequently, exophthalmos develops, which at first is asymmetrical or unilateral.
At the stage of advanced clinical manifestations, these symptoms of endocrine ophthalmopathy become permanent; These include a noticeable increase in the protrusion of the eyeballs, injection of the conjunctiva and sclera, swelling of the eyelids, diplopia, and headaches. The inability to completely close the eyelids leads to the formation of corneal ulcers, the development of conjunctivitis and iridocyclitis. Inflammatory infiltration of the lacrimal gland is aggravated by dry eye syndrome.
Complications
With severe exophthalmos, compression of the optic nerve may occur, leading to its subsequent atrophy. Mechanical restriction of the mobility of the eyeballs leads to an increase in intraocular pressure and the development of so-called pseudoglaucoma; in some cases, retinal vein occlusion develops. Involvement of the eye muscles is often accompanied by the development of strabismus.
Diagnostics
The diagnostic algorithm for endocrine ophthalmopathy involves examining the patient by an endocrinologist and ophthalmologist, performing a set of instrumental and laboratory procedures.
1.Endocrinological examination is aimed at clarifying the function of the thyroid gland and includes the study of thyroid hormones (free T4 and T3), antibodies to thyroid tissue (Ab to thyroglobulin and Ab to thyroid peroxidase), and ultrasound of the thyroid gland. If thyroid nodules with a diameter of more than 1 cm are detected, a puncture biopsy is indicated.
2.Functional ophthalmological examination for endocrine ophthalmopathy, the goal is to clarify visual function. The functional block includes:
- biometric studies of the eye (exophthalmometry, measurement of the angle of strabismus) - allow you to determine the height of the eye and the degree of deviation of the eyeballs
3.Visualization methods aimed at morphological assessment of eye structures. Includes the following studies:
- examination of the fundus (ophthalmoscopy) is performed to exclude the development of optic neuropathy
- biomicroscopy - to assess the condition of eye structures
- tonometry - performed to detect intraocular hypertension
- Ultrasound, MRI, CT of the orbits) make it possible to differentiate endocrine ophthalmopathy from tumors of the retrobulbar tissue.
4. Immunological examination. In case of endocrine ophthalmopathy, examination of the patient’s immune system is extremely important. Changes in cellular and humoral immunity in endocrine ophthalmopathy are characterized by a decrease in the number of CD3+ T-lymphocytes, a change in the ratio of CD3+ and lymphocytes, and a decrease in the number of CD8+ T-cynpeccors; an increase in the level of IgG, antinuclear antibodies; an increase in the titer of Ab to TG, TPO, AMAb (eye muscles), and the second colloidal antigen. If indicated, a biopsy of the affected extraocular muscles is performed.
Exophthalmos in endocrine ophthalmopathy should be differentiated from pseudoexophthalmos, observed with a high degree of myopia, orbital cellulite (phlegmon of the orbit), tumors (hemangiomas and sarcomas of the orbit, meningiomas, etc.).
Treatment of endocrine ophthalmopathy
Pathogenetic therapy
Therapeutic tactics are determined by the stage of endocrine ophthalmopathy, the degree of dysfunction of the thyroid gland and the reversibility of pathological changes. All treatment options are aimed at achieving a euthyroid state.
- Immunosuppressive therapy. Includes the administration of glucocorticoids (prednisolone), which have anti-edematous, anti-inflammatory and immunosuppressive effects. Corticosteroids are used orally and as retrobulbar injections. If there is a threat of vision loss, pulse therapy with methylprednisolone and orbital x-ray therapy are performed. The use of glucocorticoids is contraindicated for gastric or duodenal ulcers, pancreatitis, thrombophlebitis, arterial hypertension, bleeding disorders, mental and oncological diseases. instillation of drops, application of ointments and gels, taking vitamins A and E. Physiotherapy methods for endocrine ophthalmopathy include electrophoresis with lidase or aloe, and magnetic therapy on the orbital area.
Possible surgical treatments for endocrine ophthalmopathy include three types of ophthalmologic surgeries:
- Orbital decompression. It is aimed at increasing the volume of the orbit and is indicated for progressive optic neuropathy, severe exophthalmos, corneal ulcerations, subluxation of the eyeball, and other situations. Orbital decompression (orbitotomy) is achieved by resection of one or more of its walls and removal of retrobulbar fat.
- Operations on the extraocular muscles. Indicated for the development of persistent painful diplopia and paralytic strabismus, if it cannot be corrected with prismatic glasses.
- Operations on the eyelids. They represent a large group of various plastic and functional interventions, the choice of which is dictated by the developed disorder (retraction, spastic volvulus, lagophthalmos, prolapse of the lacrimal gland, hernia with loss of orbital fat, etc.).
Forecast
In 1-2% of cases, a particularly severe course of endocrine ophthalmopathy is observed, leading to severe visual complications or residual effects. Timely medical intervention allows you to achieve induced remission and avoid severe consequences of the disease. The result of therapy in 30% of patients is clinical improvement, in 60% - stabilization of the course of endocrine ophthalmopathy, in 10% - further progression of the disease.
Endocrine ophthalmopathy is a disease in which the soft tissues of the eye are damaged, which develops due to pathology of the thyroid gland. Endocrine ophthalmopathy is expressed mainly by exophthalmos and swelling with inflammation of the eye tissue. To diagnose endocrine ophthalmopathy, examinations such as exophthalmometry, biomicroscopy and orbital CT are prescribed. Tests are also carried out to determine the state of the immune system.
Causes of endocrine ophthalmopathy
Endocrine ophthalmopathy may appear during the first autoimmune processes in the thyroid gland.
What provokes the appearance of ophthalmopathy is not fully understood. But the main triggers for development are factors such as respiratory infections and smoking, low-dose radiation and heavy metal salts, as well as stress and autoimmune diseases such as diabetes. Mild forms of endocrine ophthalmopathy occur most often in young people, but the severe form is typical for older people.
It turns out that when a mutation occurs, T-lymphocytes begin to interact with receptors in the membranes of eye muscle cells and provoke the formation of specific changes in them. The autoimmune reaction of T lymphocytes provokes the release of cytokines, which in turn induce the proliferation of fibroblasts, the production of collagen and glycosaminoglycans. The production of glycosaminoglycans forms edema when binding water and contributes to an increase in the volume of ratrobulbar fiber. Such swelling of the orbital tissue is replaced over time by fibrosis, which ultimately leads to the irreversible process of exophthalmos.
Classification of endocrine ophthalmopathy
With the development of endocrine ophthalmopathy, several phases of inflammatory exudation, infiltration and a phase of proliferation and fibrosis are observed.
There are also three stages of endocrine ophthalmopathy: thyrotoxic exophthalmos, edematous exophthalmos and endocrine myopathy. Let's take a closer look at them.
Thyrotoxic exophthalmos
Thyrotoxic exophthalmos is characterized by true or false protrusion of the eyeball, and there is also a lag of the eyelid when the eye droops and excessive shine.
Edema exophthalmos
Edematous exophthalmos manifests itself with a pronounced protrusion of the eyeball by two to three centimeters and bilateral swelling of the periorbital tissues. There is also a sharp deterioration in the mobility of the eyeballs. In the future, endocrine ophthalmopathy progresses with complete ophthalmoplegia and non-closure of the palpebral fissures, corneal ulcers - a process that takes place in the cornea of the eye, along with which the formation of a crater-shaped ulcerative defect appears. This disease occurs with decreased vision and clouding of the cornea.
Endocrine form
The endocrine form of myopathy most often affects the rectus oculomotor muscles and ultimately leads to diplopia, the so-called lack of eye movement, strabismus.
To determine the severity of ophthalmopathy, the Baranov degree table is used, so to determine the first degree the following criteria will be required:
- mild exophthalmos;
- slight swelling of the eyelid;
- intact conjunctival tissues;
- muscular mobility of the eyes is not impaired.
For the second degree there is the following characteristic:
- moderate severity of exophthalmos;
- swelling of the eyelid is significantly increased compared to the first degree;
- the presence of swelling of the conjunctiva.
The third degree of endocrine ophthalmopathy differs from the two previous degrees by pronounced diplopia and corneal ulcers; atrophy of the optic nerve also occurs, with complete destruction of the nerve fibers that transmit visual irritation from the retina to the brain. This atrophy of the optic nerve provokes complete loss of vision.
Symptoms of ophthalmopathy
Early clinical manifestations of ophthalmopathy are characterized by decreased pressure in the eye, dryness or, on the contrary, lacrimation, the presence of unpleasant sensations from bright light, and swelling of the periorbital area of the eye. In the future, exophthalmos develops, the presence of which initially has an asymmetric or unilateral development.
During the period of already clearly noticeable manifestations of the clinical symptoms of endocrine ophthalmopathy, signs of enlarged eyeballs, swelling of the eyelids, as well as pronounced headaches begin to appear. Also, with incomplete closure of the eyelid, the appearance of corneal ulcers and conjunctivitis is ensured.
Severe exophthalmos leads to compression of the optic nerve and its further atrophy. Also, exophthalmos in the presence of endocrine ophthalmopathy requires more careful clarification and comparison of its differences from pseudoexophthalmos; this often occurs with an increased degree of myopia or various tumors such as orbital sarcoma or meningioma.
When the mobility of the eyeballs becomes impossible, pressure inside the eye occurs and pseudoglaucoma develops.
Diagnosis of endocrine ophthalmopathy
In diagnosis, concomitant diffuse toxic goiter is of particular, but not the only and most important, importance. In the presence of a characteristic bilateral process, the patient is diagnosed almost immediately. It is quite rare to use ultrasound to determine the thickness of the extraocular muscles.
In a number of cases, such a study is carried out for the active diagnosis of clinically unexpressed endocrine ophthalmopathy; its determination makes it possible to identify toxic goiter in cases where it is difficult to distinguish from other diseases that develop with thyrotoxicosis. An MRI study has the same function; it is the most informative analysis in this case. The main reason for prescribing this study is the indication for a patient with unilateral exophthalmos, to exclude a retrobulbar tumor.
When diagnosing diabetic ophthalmopathy, it is important to establish the activity of endocrine ophthalmopathy using the clinical picture before prescribing treatment. For this, there is a scale of clinical activity from one to seven points:
- Spontaneous retrobulbar pain;
- Painful sensations when making eye movements;
- Redness of the eyelids;
- Swelling;
- Conjunctival injections;
- Chemosis;
- Swelling of the caruncle.
Endocrine ophthalmopathy on this scale is considered active from four points.
Treatment of endocrine ophthalmopathy
Treatment is carried out jointly with an ophthalmologist and an endocrinologist, taking into account the severe stages of the disease and defects in the functioning of the thyroid gland. Successful treatment is verified by achieving a stable euthyroid state.
Hypothyroidism and thyrotoxicosis have an adverse effect on the course of endocrine ophthalmopathy; deterioration of the condition is also recorded with a fairly rapid transition from one to another condition, therefore, after applying surgical treatment, it is worth clearly monitoring the level of thyroid hormones in the blood, and preventive measures should be taken in relation to hypothyroidism.
Features of the treatment of endocrine ophthalmopathy
Quite often, the clinical picture of endocrine ophthalmopathy is observed in patients without clinical disorders of the thyroid gland. In such patients, examination may reveal subclinical thyrotoxicosis or subclinical hypothyroidism, and the absence of pathological changes is also possible. In the absence of any pathological changes, a test with thyrotropin-releasing hormone is prescribed. Next, the patient is observed by an endocrinologist, who carries out dynamic monitoring of the thyroid status.
When determining treatment, it should also be understood that the disease has the property of spontaneous remission. Treatment is also prescribed taking into account the severity and activity of the disease.
What treatment is provided for different stages of the disease?
For any severity of the disease, it is necessary to stop smoking and protect the corneas with drops, and wear dark glasses.
- With a mild form of ophthalmopathy, only process control is carried out without intervention.
- With moderate severity of ophthalmopathy and the active phase, anti-inflammatory therapy should be used. Moderate severity of ophthalmopathy and the inactive phase provoke the use of reconstructive surgery.
- For severe endocrine ophthalmopathy, pulse therapy with glucocorticoids and orbital decompression are used.
Active therapy in most cases is not used for endocrine ophthalmopathy, since the disease has a fairly mild form and is prone to natural remission, regardless of action. But still, the patient should adhere to some rules, for example, stop smoking and using eye drops.
What is needed for treatment
The main condition for remission is maintaining euthyroidism. In moderate and severe stages of endocrine ophthalmopathy, pulse therapy with methylprednisolone is often used, which is the most effective and safest method. Contraindications to the use of pulse therapy may include peptic ulcer of the stomach or duodenum, pancreatitis or arterial hypertension.
Oral prednisolone is also used, but this method has a high risk of side effects. A fairly common problem when using glucocorticoid treatment is often developing relapses of endocrine ophthalmopathy after stopping the drugs.
Radiation therapy
Radiation therapy is prescribed to people diagnosed with endocrine ophthalmopathy in both moderate and severe stages of inflammatory symptoms, diplopia and complete loss of vision. Radiation has the property of destroying orbital fibroblasts and lymphocytes. It will take a couple of weeks for the desired reaction to occur after applying radiation. During this period, the inflammatory process gains momentum. During the first couple of weeks of treatment, most people with this condition are stimulated with steroids. The best response to radiation therapy occurs in patients at the peak of the inflammatory process. Radiation may be more effective when combined with steroid therapy.
Taking into account the fact that the use of radiation therapy can influence the improvement of the situation in case of motor dysfunction, the use of radiation as a single type of treatment is not prescribed for the treatment of diplopia. Orbital irradiation for endocrine ophthalmopathy is becoming the safest treatment method. Radiation is not recommended for people with diabetes because of the potential for worsening retinopathy.
X-ray therapy
Also, along with the use of various drugs, there is the method of radiotherapy on the orbital area with the synchronous use of glucocorticoids. X-ray therapy is used for clearly visible edematous exophthalmos, in case of ineffective treatment with glucocorticoids alone, remote irradiation of the orbits is performed from the direct and lateral fields with protection of the anterior field of the eye.
X-ray therapy has anti-inflammatory and antiproliferative effects, provokes a decrease in cytokines and secretory activity of fibroblasts. The effectiveness of radiotherapy is assessed two months after treatment. A severe form of endocrine ophthalmopathy requires the use of surgical treatment for orbital decompression. Surgical treatment is used at the stage of fibrosis.
There are also three types of surgical treatment, these are:
- eyelid surgery for corneal damage;
- corrective surgery on the motor muscles of the eyes, carried out in the presence of strabismus;
- surgical decompression of the orbits, which is used to relieve compression of the optic nerve.
In the case of minor eyelid retraction when restoring the euthyroid state, surgical treatment to lengthen the eyelid is used. This intervention reduces corneal exposure and is performed to conceal mild to moderate proptosis. For patients who are unable to operate the eyelid, instead of surgically lengthening the upper eyelid, injections of botulinum toxin and subconjunctival triamcinolone into the upper eyelid are used.
Lateral tarsorrhaphy reduces the upper and lower retraction of the eyelid; this operation is less desirable as the cosmetic results and their stability are poorer.
Drooping of the upper eyelid occurs due to dosed levator tenotomy.
This treatment is also used in the inactive phase of endocrine ophthalmopathy with pronounced visual and cosmetic disturbances. The most effective therapy is considered to be radiation with the use of glucocorticoids.
Prognosis for endocrine ophthalmopathy
Only two percent of patients have a severe form of endocrine ophthalmopathy, which leads to severe eye complications. At the current stage, medicine is at a level at which treatment helps to achieve stable remission and avoid the serious consequences of the disease.
Content
Protruding eyes are the main symptom of endocrine ophthalmopathy. This disease is also known as Graves' ophthalmopathy, named after the scientist who first described the signs of the pathology. With this condition, the posterior (retrobulbar) tissues of the organ of vision and the muscles of the eyeball are affected, which leads to its displacement. The pathology manifests itself as bulging eyes, tearing, swelling of the eyelids and conjunctiva. At an advanced stage, the optic nerve atrophies and vision deteriorates significantly.
How does Graves' ophthalmopathy manifest?
In 95% of cases, the cause of damage to the soft tissues of the orbit is diffuse toxic goiter, which develops due to thyrotoxicosis, in which the thyroid gland produces an excessive amount of iodine-containing hormones. Ophthalmopathy can manifest itself both during the disease and before its onset, and ten years later. The mechanisms by which retrobulbar tissues are affected are unclear. It is believed that the triggering factors are bacterial or rotavirus infections, intoxication of the body, radiation, stress, smoking, and insolation.
The pathology is autoimmune in nature. This is the name for a condition in which the immune system begins to attack and destroy healthy tissue, mistaking them for pathogenic cells. According to one version, the immune system perceives the fiber that surrounds the eyeball as a carrier of receptors for iodine-containing thyroid hormones. This is regarded as an abnormal condition, and in order to eliminate the problem, the immune system produces antibodies to destroy them.
Having penetrated the tissues of the orbit, antibodies cause inflammation with infiltrate (accumulation of foreign particles). In response, fiber synthesizes glycosaminoglycans - substances that attract liquid. The result is swelling of the eye tissues and an increase in the oculomotor muscles, which are responsible for pressure in the bony base of the orbit.
This leads to exophthalmos - a forward displacement of the eyeball and the appearance of bulging eyes. Sometimes it goes to the side, a symptom of which is strabismus. Over time, the inflammation subsides, the infiltrate is converted into connective tissue. In its place, a scar is formed, after which the displacement becomes irreversible.
To avoid this, it is important to notice the symptoms of pathology in time, contact an endocrinologist and begin treatment for the underlying disease. At the initial stage, endocrine ophthalmopathy cannot be treated as an independent disease. In severe cases, surgery may be prescribed. This could be surgery on the eyelids, oculomotor muscles, orbital decompression for exophthalmos.
Early signs
Ophthalmopathy with thyrotoxicosis has a favorable prognosis in treatment: in 10% of cases there is an improvement, in 60% - stabilization of the condition. For this reason, it is very important to notice early signs of the disease in time. At the initial stage, the pathology is manifested by the following symptoms:
- “sand”, a feeling of pressure in the organ of vision;
- watery or dry eyes;
- photophobia;
- swelling around the organ of vision;
- slight bulging eyes.
Stage of advanced clinical manifestations
As endocrine ophthalmopathy develops, the situation worsens. A symptom of this condition is a noticeable enlargement of the eyeballs, redness of the whites, swelling of the eyelids, and double objects. Due to the fact that the eyes are unable to close completely, ulcers form on the cornea, conjunctivitis and iridocyclitis develop - inflammation of the iris and ciliary body. Dry eye syndrome often develops.
At the severe stage of endocrine ophthalmopathy, the optic nerve atrophies, eye mobility is limited, which causes intraocular pressure to increase and pseudoglaucoma develops. Retinal vein occlusion (blockage) may occur, leading to vision loss. If the pathological process affects the muscles of the organ of vision, strabismus often develops.
Classification
There are several types of classification of endocrine ophthalmopathy. Depending on the manifestations of symptoms, three stages of pathology are distinguished:
- The first degree is characterized by slight bulging eyes, when the eyeball protrudes forward no more than 16 mm. Symptoms of this stage are moderate swelling of the eyelids, without disruption of the oculomotor muscles and conjunctiva.
- The second degree of endocrine ophthalmopathy is characterized by protrusion of the eyeball by 18 mm. At this stage, there is severe swelling of the eyelids and conjunctiva, and periodic double vision.
- A symptom of the third degree is pronounced bulging eyes: the forward deviation is up to 21 mm. The patient cannot completely close his eyes, erosions and ulcers appear on the cornea, the eyeball loses mobility, and the optic nerve atrophies.
Features of symptoms depending on the type of disease
In medical practice, there are three forms of pathology - thyrotoxic exophthalmos, edematous form, endocrine myopathy. The symptoms of these varieties have some differences, as can be seen from the following table:
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Type of endocrine ophtolopathy |
Symptoms |
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Thyrotoxic exophthalmos |
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Edema exophthalmos |
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1st stage of compensation |
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Stage 2: subcompensatory |
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Stage 3: decompensatory |
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Endocrine myopathy |
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In most cases, this type of endocrine ophthalmopathy is observed in men against the background of increased production of iodine-containing hormones by the thyroid gland. The pathology is accompanied by the following symptoms:
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