Does Graves’ Ophthalmopathy Go Away?

Graves’ ophthalmopathy, also called Graves’ orbitopathy or thyroid eye disease is a condition in which the body’s immune system attacks the tissues around the eyes.

• This autoimmune response results in the enlargement or swelling of fats and tissues around the eyes, leading to bulging eyes with various vision issues.
• The swollen tissues cannot be accommodated within the eye orbit, and this pushes the eyeball outward giving the face a staring look.
• The swollen muscles cannot move the eyeball properly, which interferes with vision. 
• The bulged eyeball cannot be adequately covered by the eyelids, leading to problems such as drying and irritation of the eyes and risks of frequent eye infections.

Graves’ ophthalmopathy risk factors

Graves’ ophthalmopathy affects about one million Americans with risk factors that include:

• Women are five to six times more likely to get Graves’ ophthalmopathy than men. 
• Cigarette smoking increases the risk of Graves’ ophthalmopathy. Smokers may have a more severe disease course than nonsmokers.

Graves’ ophthalmopathy occurs in about half of the people with Graves’ disease.

• Graves’ disease is an autoimmune condition in which the body’s immune system attacks its thyroid gland.
• The thyroid gland is a butterfly-shaped gland located in front of the neck that produces thyroid hormones, which regulate metabolism and influence various important parameters, such as heart rate, body temperature, reproduction, and digestion.
• Graves’ disease results in the overproduction of thyroid hormones, resulting in various metabolic disturbances.

Although Graves’ disease and Graves’ ophthalmopathy have a common cause (autoimmune attack), they do not influence each other. This means that both diseases have a separate course, and improvement in one does not necessitate improvement in the other.

Thus, although treatment of Graves’ disease is essential, it may not lead to an improvement in Graves’ ophthalmopathy. Some people may even notice worsening eye symptoms despite improvement in their thyroid profile.

Symptoms of Graves’ ophthalmopathy generally include:

• Dryness or gritty feeling in the eyes
• Eye irritation
• Watery eyes
• Exophthalmos (a bulging or staring appearance of the eyes)
• Difficulty in eye movement
• Diplopia (double vision)
• Blurred vision
• Eye pain particularly on moving the eyes
• Intolerance to bright light
• Puffy or swollen eyelids
• Headache

With increased swelling of the tissues around the eyes, there may be consequent compression of the nerve that carries vision sensation from the eyes to the brain (optic nerve). This may result in deterioration of vision; however, complete loss of vision or permanent blindness rarely occurs in Graves’ ophthalmopathy.

Sight-threatening eye disease affects about three to five percent of people with Graves’ disease. The warning sign is loss of colored vision that requires urgent medical attention.

There may be additional symptoms of Graves’ disease such as:

• Rapid heartbeat or palpitations
• Increased sweating
• Hand tremors
• Enlarged thyroid gland (seen as swelling in front of the neck that moves on swallowing)
• Irritability
• Anxiety
• Difficulty sleeping
• Intolerance to heat
• Menstrual disturbances
• Reduced libido
• Unexplained weight loss
• Weak bones (increased risk of fractures)

There may be associated skin changes called pretibial dermopathy or myxedema. It presents as reddish and thickened skin on the shin. Skin changes may occur on the feet and rarely other sites such as swelling over the hands or clubbing of the toes and fingers.

Treatment of Graves’ ophthalmopathy mainly depends on the severity of the condition, any underlying diseases (such as diabetes), and whether associated hyperthyroidism is present. 

Treatment may consist of the following:

• Topical medications: These include eye drops that help reduce eye discomfort and dryness. The doctor may prescribe artificial tears, saline eye drops, or other lubricating eye ointments or gels.
• Eye care: This may consist of wearing sunglasses and using eye patches or covers if the eyelids cannot shut completely. Applying cool compresses over the eyes may provide comfort and help keep the eyes clean. Your doctor may suggest you sleep with your head elevated to reduce fluid buildup or swelling around the eyes. Corrective glasses with prisms may help relieve diplopia.
• Quit smoking: Smoking can worsen the progression of Graves’ ophthalmopathy. If you smoke, you must quit it to relieve your symptoms and prevent further complications in your eyes.
• Steroids: The doctor may give steroid medications, called glucocorticoids, for moderate to severe eye disease. They may give steroids (such as prednisone or methylprednisolone) orally or intravenously (IV). Steroids may be avoided in people with poorly controlled diabetes.
• Radiation: It consists of X-rays to destroy excessive tissue buildup behind the eyes. It may be tried in people with severe eye disease who do not respond to steroid medications.
• Correction of thyroid hormone imbalance: Medications may be given to treat hyperthyroidism when present. Often, there is a risk of hypothyroidism (low thyroid levels) after hyperthyroidism is treated. Thyroid levels are then normalized through medications because hypothyroidism can worsen eye symptoms.
• Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs may help relieve swelling and pain in some people.
• Teprotumumab: This medication was recently approved by the U.S. Food and Drug Administration for the treatment of Graves’ ophthalmopathy. It must be given in an IV every three weeks for a total of eight infusions. This medication cannot be given during pregnancy.
• Surgery: Surgery may be performed in people with severe Graves’ ophthalmopathy who are at risk of losing vision. Surgery helps preserve vision, improve cosmetic appearance, and relieve eye symptoms such as pain, irritation, and difficulty moving the eyes.