Graves-related eye disease

The majority of patients with Graves disease have minimal eye involvement. The relationship between eye disease and Graves disease is not completely understood, but relates to an immunological disorder. Eye disease can be difficult to manage and can occasionally threaten vision, as well as being severely disfiguring.

If Graves-related eye disease is suspected, assess the patient’s visual acuity and fields, and their ability to close the eyes to achieve corneal protection. If any of these is compromised, the patient’s vision may be acutely threatened—refer them to the emergency department for urgent specialist management. Patients without an acute threat to vision require nonurgent referral to an ophthalmologist for more detailed assessment.

Achieving euthyroidism (usually with antithyroid drugs) is an important initial aim of therapy as euthyroidism is thought to decrease risk. However, eye disease can progress unpredictably, sometimes without a clear relationship to the severity of hyperthyroidism.

The association between smoking and Graves-related eye disease is well established. Counsel all patients with Graves disease not to smoke, because of the potential to exacerbate severe eye disease; see also Smoking cessation.

For patients with conjunctival irritation and dryness, or reactive lacrimation, use:

Severe Graves-related eye disease is a complex condition and treatment requires both ophthalmologist and endocrinologist involvement. If vision is threatened, weekly intravenous methylprednisolone (first line) or high-dose oral prednisolone (or prednisone) (second line) can be used.

Selenium can also be used—a randomised controlled trial of selenium versus placebo in patients with active mild Graves-related eye disease demonstrated that selenium can improve clinical manifestations and quality of life, and reduce progression to severe disease¹.