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A Summary of Information for Patients

Chase A Liaboe, BA (M4), Brittany A. Simmons, MD*, Thomas J Clark, MD, Erin M Shriver, MD

September 1, 2016; updated January 9, 2017; *updated January 17, 2020

Introduction

Thyroid eye disease (TED) is an inflammatory disease of the eye and the surrounding tissues. The inflammation is due to an autoimmune reaction - the body's immune system is attacking tissues within and around the eye socket. TED is sometimes referred to by other names, such as Graves' ophthalmopathy, Graves' orbitopathy, thyroid-associated ophthalmopathy, and/or thyroid orbitopathy.

About 90% of TED patients also have Graves' disease, an autoimmune disorder that causes excess thyroid hormone production (hyperthyroidism). However, 10% of patients with TED have either a normal-functioning or under-functioning thyroid (e.g. Hashimoto's thyroiditis). While control of systemic thyroid hormone levels is crucial in patients with TED, the ocular disease course and severity does not always correlate with thyroid hormone levels.

Most patients with TED have signs and/or symptoms in both eyes, however the severity can differ between the eyes. Some of the most common manifestations of TED:

Swelling in and around the eye socket
Retraction (tightening) of the eyelids
Strabismus (the eyes are not in alignment with each other) and diplopia (double vision)
Dry, irritated, red eyes

More severe ocular effects from TED are rare, but can occur and include vision loss from damage to the optic nerve and breakdown/infection of the cornea (the transparent, outermost layer of the eye that we see through).

Figures 1 and 2. These patients have some of the classic signs and symptoms of TED. Note the swelling around the eye, retraction of the eyelid, and injection of the conjunctiva.

Epidemiology

TED is the most common cause of both orbital disease and exophthalmos (external protrusion of the eyeball from the socket) in North America and Europe.
TED occurs more frequently in women than in men, with both sexes having two age ranges in which TED is most likely to be diagnosed.
- Females
  - 16 per 100,000 (0.016%) females have TED
  - Most diagnoses occur between 40-44 and 60-65 years old
- Males
  - 3 per 100,000 (0.003%) males have TED
  - Most diagnoses occur between 45-49 and 65-69 years old
Risk factors for the development of TED include the following
- Age (see above age ranges)
- Sex (females more likely to be diagnosed with TED)
- Ethnicity (higher incidence among people of black and Asian/Pacific Island ethnicity) [1]
- Family history of TED or other thyroid disorders
- Smoking, or exposure to tobacco smoke
- Thyroid dysfunction (particularly hyperthyroid) [2]
- Presence of thyroid stimulating hormone receptor antibodies/thyroid stimulating immunoglobulin [3]
- Radioactive iodine therapy [4]
The signs, symptoms, and severity of TED can be worsened by both genetic and environmental factors.
- Smoking or exposure to cigarette smoke
  - Smokers are twice as likely to develop Graves' disease
  - Smokers with Graves' disease are over 7x more likely to develop TED, when compared to nonsmokers
  - Smokers tend to have a longer duration of the active phase of TED (2-3 years for smokers, compared to 1 year for nonsmokers)
- Selenium deficiency [5] (see Selenium)
- Vitamin D deficiency [6]
- Increased stress levels (see Stress reduction)

Mechanism of TED

TED is caused by an inflammatory response involving the tissues in and around the eye socket.

TED patients produce autoantibodies (proteins of the immune system that aberrantly react against the body's own cells) that bind to fibroblast cells within the eye socket
When these antibodies bind, they cause the fibroblast cells to produce and release chemical signals and biologic materials that lead to swelling and congestion in and around the eye socket
The main autoantibody produced by TED patients is known as Thyroid Stimulating Immunoglobulin (TSI), and this autoantibody can be measured in the blood to help monitor disease activity
- The amount of TSI present in a TED patient correlates with TED severity
- However, sometimes TED can occur without TSI formation

Clinical Presentation of TED

About 90% of patients with TED also have some thyroid dysfunction - usually the thyroid is overactive (i.e. Graves' disease), but occasionally the thyroid is underactive (e.g. Hashimoto's thyroiditis). Most times, the diagnosis of TED and diagnosis of a thyroid dysfunction occur within the same year. Patients who are diagnosed with TED but have no known thyroid dysfunction should see their primary care physician for an evaluation of their thyroid function.

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The disease course for TED involves 2 phases - active and stable. In the active phase there is active swelling and inflammation. This presents as redness in and around the eye, eye pain with or without eye movement, as well as swelling around the eyes and eyelids. The active phase of TED involves a waxing/waning period of these symptoms, and can last months to years. On average, the active phase of TED lasts about 1 year for non-smokers, and 2-3 years for smokers (or patients exposed to smoke). The active phase of TED spontaneously transitions to the stable phase, but can recur. Active TED has a recurrence rate of about 5-10%, but is less likely to recur after 18 months in the stable phase.

Figure 3. Active vs. Stable TED. Active TED is characterized by signs of inflammation (swelling around the eye, swelling and injection of the conjunctiva, and enlargement of the muscles that move the eye). TED activity waxes and wanes, and usually transitions to stable TED within 1-3 years.

Figure 4. Rundle's curve. As seen in the representation of TED activity over time in Rundle's curve, initiating therapy early is crucial to diminish the overall severity of the chronic disease.

Many patients with TED present to a physician with similar complaints. The most common signs and symptoms associated with TED are

Upper and/or lower eyelid retraction - the eyelid is pulled away from its normal resting position
- Affects up to 90% of TED patients, and can affect one or both eyes
- On exam, there is a larger palpebral fissure (the space between the upper and lower eyelids) and the eyes have a characteristic 'startled/surprised' appearance
- In cases of severe retraction, it may become difficult to close the eyelids at rest, leading to dry eyes, which can lead to tearing, foreign body sensation, and blurred vision
  - It is important to treat dry eyes, starting with liberal use of preservative-free eye drops, in addition to eye ointment at night

Figure 5. Eyelid retraction is the most common presenting sign of TED, and is the result of many factors associated with TED.

Figure 6. Lagophthalmos is the inability of the eyelid to fully close. It typically presents as dry eye, tearing, foreign body sensation, and blurred vision. The united states in world war ii pdf free. downl

Ted &amp; Me PDF Free Download

Ted & Me PDF Free Download