Autoimmune Endocrine Disease and the Eye Study Guide

Introduction

Autoimmune diseases have a variety of systemic manifestations; the eye is frequently involved in numerous autoimmune and rheumatologic disorders. Ocular manifestations are frequently nonspecific and different diseases may affect different parts of the eye, but early recognition of symptoms can help avoid or delay both systemic and ocular sequelae.

The most common autoimmune diseases that affect the eyes can be separated into four categories:

1. Rheumatologic
2. Dermatologic
3. Endocrine
4. Vascular

This is part three of a four-part series in which we discuss Graves’ disease, an autoimmune endocrine disease that affects the eye.

Graves’ disease^1-10

Graves’ disease - epidemiology

• Eye manifestations
  • All cases of Graves Ophthalmopathy
    • 9-15 per 10,000
  • Secondary to Graves Hyperthyroidism
    • 25%

Graves’ disease - mechanism

• Thyroid-stimulating hormone receptor antibodies & active T-cells activate retroocular fibroblast & adipocytes receptors 🡪
  • Retro-orbital inflammation
  • Fibroblast proliferation
  • Accumulation of hydrophilic glycosaminoglycans

Graves’ disease -risk factors

• Genetics
• Sex (women > men)
• Smoking (OR: 2.22)
• Radioiodine therapy

Graves’ disease - presentation

• Asymptomatic
• Exophthalmos
• Proptosis and choroidal folds
• Periorbital edema
• Feeling of pressure behind eye
• Gritty/foreign body sensation
• Excessive tearing
• Discomfort/pain
• Blurry vision
• Diplopia
• Color vision desaturation
• ↓ Vision

Graves’ disease - diagnosis

• Labs (Grave’s Hyperthyroidism)
  • ↓ TSH
  • ↑ Free T3, T4
  • + TSH receptor antibodies
• Imaging
  • Non-contrast CT
    • Baseline image of orbits
    • Risk of optic nerve compression by extraocular muscles
    • Measurement of
      • Proptosis
      • Retroocular fat accumulation

Disease Activity

Assessment of Graves’ Orbitopathy: Clinical Activity Score