GRAVE’S DISEASE – Thyroid Related Orbitopathy

 

GRAVE’S DISEASE; BASEDOW’S DISEASE, EXOPHTHALMIC GOITRE.—The most prominent characteristics of this affection are an irritability of the heart with increased frequency of the pulse, and enlargement of the thyroid gland and a swelling of the tissues of the orbit, which cause the eyeballs to become prominent. The size of the goitre and the amount of protrusion of the eyeball vary very much in different cases. Frequently there is a symptom to which Graefe was the first to call attention—namely, a disturbance of the usual consensual movements of the eyeball and upper eyelid.  The appearance of a bulging eye with the eyelids retracting and the sclera showing superiorly and inferiorly is is called scleral show.  This is clasic for Graves Disease.  Proptosis can be related to an orbital lesion or racial factors.   Blacks tend to have more prominent eyes (Racial Proptosis) than whites.  Normal Hertel measurements vary by race.

When the patient looks downward below the horizontal line, the lid no longer accompanies the eyeball in its motion, but halts in its course. This derangement in the action of the lid is supposed to depend upon some defect in the innervation of the orbicularis, as it is not present in cases of equal prominence of the eyeball from other causes. The amount of secretion from the tear-glands and from the conjunctival surface is also at times much diminished. Owing to the prominence of the eyes and the relaxation of the orbicularis, the fissure of the lids is wider open than usual, and the eye has a peculiar stare. At times, when the prominence of the eyes is very great, the lids fail to cover the balls during sleep, and the cornea becomes inflamed and ulcerated from exposure to air and dust. The disease rarely develops till after puberty, and is more frequent in females than in males: in the former it often develops after childbirth. It is so frequently accompanied by disease of the reproductive organs that Foerster, in his paper on the “Relation of Eye Diseases to General Disease,”²⁹¹ places it in the section devoted to eye symptoms from diseases of the sexual organs. Ophthalmoscopic examination usually shows a slight thickening of the fibre-layer of the retina in and around the disc, with dilatation and tortuosity of the veins—a state of affairs which may often [p. 800]be fairly attributed to venous stasis caused by the swelling tissues. In addition to these symptoms there is sometimes, as Becker has pointed out, a dilatation of the arteries, which may almost equal the veins in calibre. At times there is an arterial pulse. As found by autopsies, the anatomical changes are usually enlargement and dilatation of the heart, hypertrophy and various degenerative changes in the thyroid glands, and a state of hyperæmia at times associated with hypertrophy of the fat tissue of both orbits.

²⁹¹ Graefe und Saemisch, vol. vii. p. 97.