Graves’ Disease

What is Graves’ Disease?

Graves’ disease is an autoimmune disorder that affects the thyroid gland, the butterfly-shaped gland located in the lower front of the neck. Graves’ disease causes the thyroid gland to produce excess amounts of thyroid hormone (hyperthyroidism).

Symptoms of Graves’ Disease

Graves’ disease can cause eye and skin changes. Such symptoms may occur before or after a person is diagnosed with Graves’ disease. In many cases, these symptoms resolve with treatment.

Eye symptoms associated with Graves’ disease may include:

  • Redness
  • Swelling around the eyes
  • Bulging eyes/ inflammation 
  • Rarely, diminished or double vision

Most Graves’ disease-related eye problems (called Graves’ ophthalmopathy) are mild and are not permanent. They are more frequent and serious among patients who smoke, however.

Skin symptoms are not common, but some patients with Graves’ disease develop red, thickened skin on the front of the shins. This is called pretibial myxedema and is usually mild, but occasionally can be painful.

Other symptoms of Graves’ disease may include:

  • Goiter (enlarged thyroid)
  • Weight loss
  • Anxiety, irritability, restlessness
  • Difficulty sleeping
  • Irregular menstrual cycles
  • Muscle weakness
  • Difficulty controlling diabetes
  • Chest pain/heart palpitations
  • Intolerance to heat

Causes of Graves’ Disease

Graves’ disease is an autoimmune disease, which means that the patient’s immune system produces antibodies against his or her own tissues. In this case, antibodies bind to thyroid cells and stimulate them to overproduce thyroid hormone. The same kinds of receptors are also located behind the eyes, which is what leads to the swelling and inflammation of the eye tissues in Graves’ disease. 

It has been observed that Graves’ disease runs in families and is thought to have a hereditary component, although specific genetic causes have not yet been identified. Like other autoimmune diseases, Graves’ disease is more common among women than men.

Stress may trigger the onset of Graves’ disease in some patients. 

How is Graves’ Disease Diagnosed?

If Graves’ disease is suspected, blood tests will be done to determine the levels of thyroid-stimulating hormone (TSH), T3 (triiodothyronine), and T4 (thyroxine) hormone levels. Additional tests for antibody levels may also be performed. 

If a patient has symptoms of eye disease further testing may be required to determine the extent of the eye disease. 

A radioactive iodine uptake test may be performed to determine the cause of the overactive thyroid, since there are other causes in addition to Graves’ disease. This painless test involves swallowing a radioactive tracer ‘pill’ and then performing a scan of the thyroid.  The radioactive iodine scan is helpful in making a diagnosis of the hyperthyroidism and it determining the next steps in treatment.

How is Graves’ Disease Treated?

There are three primary approaches to treating Graves’ disease.

Antithyroid medications such as Methimazole are used to inhibit the thyroid from producing hormone thyroid hormone. This medications can cause side effects including nausea, vomiting, heartburn, headache, joint or muscle aches, loss of taste, and a metallic taste. These are usually temporary. If a patient is allergic to the medication, it may cause skin rashes or hives. Antithyroid medications carry a rare risk of agranulocytosis, an insufficient supply of white blood cells that can leave patients susceptible to infection.

Radioactive Iodine may be administered by capsule or solution to destroy thyroid tissue, thereby decreasing the production of thyroid hormones.  As a result of this treatment many patients develop hypothyroidism, meaning the body no longer produces enough thyroid hormones.

Surgery may be the best option for patients who cannot tolerate antithyroid medications, who may be pregnant (or are planning to become pregnant), or who may require surgical removal of a goiter.  During surgery for Graves’ disease, most of the thyroid may be removed. Total removal of the thyroid (thyroidectomy) results in hypothyroidism, which will require patients to take daily thyroid replacement hormones.

Graves’ Related Eye Disease

Graves’ Related Eye Disease: Medical Treatment 

Early eye symptoms, such as dryness, redness, itching, swelling of the lids and inability to wear contact lenses, are usually mild. Some patients find these symptoms to be particularly irritating at night and during exposure to air conditioning, hot air heating, and wind. A few patients will develop double vision (diplopia), which is the result of asymmetric inflammation of the muscles that control eye movement. Many patients develop mild symptoms that are often misdiagnosed as an "ocular allergy." Therefore, Graves' disease patients should be followed by an ophthalmologist familiar with the condition and available treatments. Patients with mild symptoms can often be successfully treated with frequent use of lubricating eye drops and wearing eye covers at night. Humidification of room air can prevent drying of the eyes, and wrap-around polarizing sunglasses can also help relieve glare. Diplopia can be improved by wearing special prism lenses while awaiting either spontaneous improvement or surgical correction. Temporary plastic prisms may be put on a regular set of eyeglasses and changed as needed. Prednisone, a steroid medication, may be taken in pill form to provide temporary relief from pain, swelling and redness, although side effects of the medication may limit its use.

Graves’ Related Eye Disease: Surgical Treatment

If ocular Graves' disease does not improve or if it gets worse despite treatment, surgery may be required. Retracted and puffy eyelids can change a person's appearance and increase the risk of the cornea drying. Corrective eyelid surgery can improve this problem through loosening of the eyelid muscles, as well as removal of scar tissue, excess fatty tissue and skin to place the eyelids into a more normal position. Surgery may also be necessary to correct diplopia when this problem has not improved either spontaneously or with prism lenses. Surgery to correct diploplia involves disconnecting and repositioning the muscles that control eye movement to improve ocular alignment and minimize double-vision.

The enlargement of tissue behind the eye may sometimes cause significant bulging of the eye (exophthalmos), which produces the characteristic wide-eyed stare seen in ocular Graves' disease. Swelling in the orbit may also contribute to vision loss as pressure increases on the optic nerve. Surgical procedures to reduce pressure on the optic nerve can improve vision and allow the eye to settle back to a more normal position. Orbital decompression is indicated in patients with significant exophthalmos, visual loss, or severe exposure of the corneas. Orbital decompression involves surgical removal of fat from behind the eyeball and may also involve removing some of the bone surrounding the eye socket.

For most patients, surgery is performed under general anesthesia and usually requires an overnight hospital stay.

Learn more about surgical options for Graves’ disease here.