Why is this happening
In diffuse toxic goiter, the immune system produces antibodies to TSH receptors. The same receptors are present on the cells of the fatty tissue of the orbit, so antibodies stimulate them: the cells begin to accumulate substances that attract water, the volume of tissue grows, and the oculomotor muscles thicken. Ophthalmopathy can appear before, simultaneously with, or years after thyroid problems, and sometimes occurs with normal or even decreased thyroid function. Smoking increases inflammation in the orbit several times and worsens the response to treatment.
- Autoimmune reaction against orbital tissue
- Association with diffuse toxic goiter
- Possible with normal thyroid function
- Smoking is the main modifiable risk factor
- Sharp fluctuations in hormones worsen the course
Symptoms and stages
Early complaints are nonspecific: a feeling of sand, lacrimation, photophobia, swelling of the eyelids in the morning, a feeling of pressure behind the eyes. Then the protrusion of the eyes becomes noticeable, the palpebral fissure widens, the upper eyelid lags behind when looking down, the gaze seems intent. When muscles are involved, double vision appears, first in the morning and when looking to the side. The doctor separately evaluates the activity of inflammation - pain, redness of the eyelids and conjunctiva, swelling - and severity, that is, the degree of protrusion and dysfunction. The choice of treatment depends on activity.
- Feeling sandy and dry
- Swelling and redness of the eyelids
- Protrusion of eyeballs
- Widened palpebral fissure and rare blinking
- Double vision when looking to the side
- Pain and pressure behind the eyes
- Incomplete closure of eyelids during sleep
Survey
The endocrinologist determines TSH and free T4, antibodies to TSH receptors, and prescribes an ultrasound of the thyroid gland: the level of antibodies helps both confirm the diagnosis and assess the prognosis. The ophthalmologist measures the degree of protrusion of the eye with an exophthalmometer, checks visual acuity, color perception, visual fields, eye mobility and the condition of the cornea, and measures intraocular pressure in different gaze positions. An MRI or CT scan of the orbits shows muscle thickening, fat volume, and whether the optic nerve is compressed at the apex of the orbit. The examination is repeated over time.
- TSH and free T4
- Antibodies to TSH receptors
- Ultrasound of the thyroid gland
- Exophthalmometry
- Checking visual fields and color perception
- MRI or CT of the orbits
- Corneal condition assessment
Treatment
The first steps are the same for everyone: complete cessation of smoking, including passive smoking, and achieving stable normal thyroid function under the supervision of an endocrinologist. For mild forms, moisturizing drops and gels, sleeping with the head of the bed elevated, dark glasses and eye protection when outdoors are sufficient. In case of active inflammation, systemic glucocorticosteroids are used according to the scheme; if the effect is insufficient, radiation therapy of the orbits and modern targeted drugs are discussed. In the inactive phase, reconstructive operations are performed: decompression of the orbit, correction of the position of muscles and eyelids.
- Complete smoking cessation
- Compensation of thyroid function
- Moisturizing drops and gels, protecting the cornea at night
- Sleeping with the head of the bed raised
- Glucocorticosteroids in the active phase
- Radiation therapy of the orbits according to indications
- Orbital decompression and muscle and eyelid surgery
Forecast and observation
The active phase usually lasts from several months to two years, after which the inflammation subsides and the condition stabilizes, but some of the changes remain: the protrusion of the eye and the position of the eyelids may not return to the original without surgery. The most dangerous complication is compression of the optic nerve at the apex of the orbit with a persistent decrease in vision, so if you complain of fading colors or worsening vision, an urgent examination is necessary. Reconstructive operations are planned no earlier than after six months of stable condition, and are performed in a certain sequence.
- Regular visits to an ophthalmologist and endocrinologist
- Control of thyroid hormones
- Immediate treatment if vision deteriorates
- Operations only in the inactive phase
- Stop smoking for the entire period of treatment
- Protect your eyes from sun, wind and dust
