|Year : 1992 | Volume
| Issue : 2 | Page : 56-58
A clinico-investigative profile in Graves' ophthalmopathy
AK Khurana1, S Sunder1, BK Ahluwalia1, KC Malhotra2, S Gupta1
1 Department of Ophthalmology, Medical College, Rohtak, India
2 Department of Medicine, Medical College, Rohtak, India
A K Khurana
34,9J. Medical Enclave, Rohtak - 124 001, Haryana
Source of Support: None, Conflict of Interest: None
A clinico-investigative profile was studied in 30 patients with Graves' Ophthalmopathy (GO) (15 each with early and late). In accordance to the thyroid status 63.3% of patients were hyperthyroid and 36.7% euthyroid. There was slight female preponderence, with ratio being 1.5:1. Exophthalmometric readings were significantly high in GO patients as compared to controls. However, no significant diagnostic role of postural exophthalmometry was seen. Positional tonometery may have respectable place among the tests for early diagnosis of GO; however, it could not differentiate between hyperthyroid and euthyroid cases. Further the role of ultrasonography, if available could not be overemphasized.
|How to cite this article:|
Khurana A K, Sunder S, Ahluwalia B K, Malhotra K C, Gupta S. A clinico-investigative profile in Graves' ophthalmopathy. Indian J Ophthalmol 1992;40:56-8
| Introduction|| |
Graves' ophthalmopathy (GO) resents a wide spectrum of clinical manifestations. With minor signs such as stare, lid retraction and minimal proptosis, patients are more often diagnostic than therapeutic problems. A further source of confusion is the equivocal role of thyroid gland. Therefore, it was planned to study the pattern of eye changes in GO and to correlate it with thyroid status. Further a comparative evaluation of postural exophthalmometry, positional tonometry and orbital ultrasonography was carried out to comment on their relative importance in diagnosis.
| Material and methods|| |
Thirty patients with GO attending thyroid clinic were picked up randomly for the study. Clinical findings were elicited by taking detailed history and performing thorough ocular examination. After thorough evaluation each patient was assigned to a class according to American thyroid association (ATA) classification .
In each patient exophthalmometry was carried out in erect & supine position using Hertel's exophthalmometer. Positional intraocular pressure was recorded using Perkins hand held applanation tonometer in primary gaze and upward looking gaze. Ultrasonographic examination of both orbits was carried out with a contact B-scan unit and a standardised A-scan unit using 'Ophthascan-B apparatus' (Bio physic Medical, France).
Serum T3, T4 and TSH were estimated by radio-immunoassay technique using reagent kits supplied by (Board of Isotope & Radiation Technology, Bombay.
| Observations|| |
Out of 30 patients with GO 18 were females and 12 males with a female to male ratio of 1.5:1. The mean age was 32.73 ± 9.42 yrs (range 17-50 yrs). In accordance with thyroid status 19 (63.33%) were hyperthyroid and 11 (36.67%) euthyroid. None of the patients had hypothyroidism. Levels of T3. T4 and radioactive iodine uptake are shown in [Table - 1]. Clinical profile of patients is depicted in [Table - 2][Table - 3] and their distribution according to ATA classification in [Table - 4]. Results of postural exophthalmometry, positional tonometry and ultrasonographic evaluation are briefed in [Table - 5][Table - 6][Table - 7], respectively.
| Discussion|| |
Graves' Ophthalrnopathy (GO) is the term recently coined for the typical changes in the eye which in the literature have been variously labelled as : infiltrative ophthalmopathy, compressive ophthalmopathy, thyroid eye disease, the eye changes in Graves' disease, malignant exophthalmos, endocrine exophthalmos, dysthyroid ophthalmopathy, ocular Graves' disease, etc. The ocular condition characteristic of GO may exist in the absence of clinical or biochemical evidence of thyroid dysfunction; and when the systemic and ocular conditions exist together they may follow completely different courses . An attempt has been made in the present study to comment on clinico-investigative profile of GO.
The ratio of female to male observed was 1.5:1. In earlier reports this ratio ranged for 4:1 to 6.8:1 ,. The mean age of female and male patients was 30.11 ± 9.45 & 36.66 ± 8.09 yrs, respectively. Thus males were affected at a slightly later age. Werner observed the peak occurrence of disease in women in 3rd and 4th decades and in a slightly older age group in men .
The occurrence of GO in hyperthyroid as well as euthyroid states in the present study is well documented in the literature. , According to ATA classification patients were classified from class 0 to class 6 [Table - 4]. In our study 15 (50%) patients belonged to class 1. Robert  also noted that class 1 was the most frequent.
The various modalities reported in the literature for early diagnosis of GO are postural exophthalmometry , positional lOp changes  and ultra sonographic evaluation of extracular muscles11. Haurer9 reported that the exophthalmometric readings in Go patients without extraocular muscle involvement decrease by 1-3 mm on going from upright to supine position, while no such chang were observed in patients with extraocular muscle involvement. However, in the present study we could not demonstrate such postural exophthalmometric changes [Table - 5] On the contrary we observed significant increase in exophthalmometric readings in supine position when compared with that in erect position in both early & late cases of GO. Thus our observations corroborate the conclusion drawn by Frueh et al  that postural exophthalmometry has no clinical usefulness in early diagnosis of GO.
Gamblin et al  suggested that positional alterations in IOP could be a diagnostic modality for subclinical GO. Azad et a1 [t3] found an elevation of 3 mm of Hg or more in upgaze in 62.5% patients with early GO. However, Allen et al  observed an increase in IOP on upgaze in only 22% patients, and thus eroded the significance of positional tonometry. We observed a significant increase of IOP on upgaze in 53% and 87% of cases with early and late GO, respectively. Further in the present study no correlation was observed between positional IOP changes and biochemical thyroid status of patients. However, the positional IOP changes may have a significant role to play under circumstances like; in diagnosis of early GO when either eye has no exophthalmos. establishing bilateral involvement in patients with unilateral exophthalmos and monitoring the progression or response to therapy.
Controlled studies indicate that ultrasonographic changes in extraocular muscles can be demonstrated in class 0 and 1 of GO when all other clinical and laboratory values may be negative . In addition to increase in muscle thickness, erosion of temporal wall of orbit, accentuation of retrobulbar fat and perineural inflammation of optic nerve have also been demonstrated in early cases with GO , In the present study we observed marked thickening of extraocular muscles, maximum for medial rectus, followed by inferior rectus in early as well as late cases with GO. We also observed increase in retrobulbar fat on B-scan in all the cases. Thus the role of ultrasonography in diagnosing early cases without manifest clinical proptosis and in picking up bilateral changes in apparently unilateral cases is unequivocal.
| References|| |
Werner SC. Am J Ophthalmol 68 646-648. 1969.
Sergott RC & Glaser JS Surv Ophthalmol 26 (1):1-21, 1981
Duke Elder S Systems of Ophthalmology. Vol. V 1952, pp. 5367-87.
Allen C. Stetz D. Roman SH. Podos S & Som P J Clin Endocrinol Metab 61 183-187. 1985
Werner SC The thyroid : A fundamental and clinical text. New York. Harper & Row. 1971, pp. 427-28.
Werner SC. Am J. Med 18:608-612. 1955.
Liddle GW. Heyssel RM & McKenzie JM. AM J. Med 39:845-848. 1965.
Day RIM. Clinical & Pathological Manifestations. In : Werner SC, Ingbar HS, eds. The thyroid A fundamental and clinical text. New York. Harper & Row, 1971. p. 663.
Haurer J. B J Ophthalmol 40 533-557. 1957.
Gamblin GT Harper DG. Galentine P Buck DR. Chernow B & Eil C. New Engl J. Mad 308 (8) : 420-424. 1983
Coleman DJ. Jack RL. Franzen LA & Werner SC. Arch Opthalmol 88:465-471. 1972,
Frueh BR, Garher F. Grill R & Musch OC. Arch Ophthatmol 10313551356. 1985.
Azad RV. Gupta AK. Sharma SK & Tiwari HK. Proceedings of the VII Congress of European Society of Ophthalmologists, p. 526. 1985.
Werner SC. Coleman DJ & Fran7en LA. N Engl J. Med 290:1447-1450, 1974.
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7]