Recent developments in thyroid eye disease

doi:10.1136/bmj.329.7462.385

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Tom Cawood, specialist registrar (tomjcawood@eircom.net)1,
Paul Moriarty, consultant ophthalmic surgeon2,
Donal O'Shea, consultant endocrinologist1

¹ Department of Endocrinology, St Vincent's University Hospital, Elm Park, Dublin 4, Republic of Ireland
² Royal Victoria Eye and Ear Hospital, Dublin 2

Correspondence to: T Cawood

Introduction

Thyroid eye disease affects an estimated 400 000 people in the United Kingdom. This estimate is based on a UK population of 59 million (http://www.statistics.gov.uk/), a prevalence of Graves' disease of 1.85% (estimates range from 1%1 to 2.7%2), and a prevalence of thyroid eye disease in Graves' disease of 37.5% (25% to 50%3). For a sizeable minority thyroid eye disease is an extremely unpleasant, painful, cosmetically distressing, and occasionally sight threatening condition. Medical treatment has progressed little in the past 25 years and remains unsatisfactory, but recent advances in other immune mediated disorders indicate that a selective treatment for thyroid eye disease should be a realistic goal.

We discuss the clinical features of thyroid eye disease and what treatments are available. We also explore the current views on the pathogenesis of thyroid eye disease and their clinical implications.

Methods

Sources of information

We retrieved from Medline papers with “thyroid” and “eye'” anywhere in the abstract and drew further information from leading medical textbooks. We also consulted with recognised experts (R Bahn, Division of Endocrinology, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA; P Kendall-Taylor, Department of Endocrinology, University of Newcastle, Newcastle upon Tyne; A P Weetman, Department of Medicine, Clinical Sciences Centre, University of Sheffield; and W M Wiersinga, Department of Endocrinology, Academic Medical Centre, University of Amsterdam, Netherlands).

Clinical features

Thyroid eye disease is also known as Graves' ophthalmopathy and thyroid associated ophthalmopathy and is usually associated with autoimmune hyperthyroidism (Graves' disease). Its typical ocular manifestations are recognised by a variety of clinical features including pain, gritty eyes, photophobia, chemosis, diplopia, and exophthalmos. Compression of the optic nerve can, in extreme cases, lead to blindness.

Risk factors

Smoking

Once a patient has Graves' disease, the major clinical risk factor for developing thyroid eye disease is smoking.4 Patients with thyroid eye disease are four times …