New Thoughts about the Cause and Treatment of the Severe Ocular Manifestations of Graves' Disease

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Abstract
The ocular manifestations of Graves' disease are probably due to autoimmunity. Thyroglobulin and complexes of thyroglobulin and antithyroglobulin have a predilection to attach to extraocular muscle membranes in vitro. It is suggested that in vivo these molecules are directed, probably via lymphatics, to the orbit where they attach to the muscle cell membranes. B lymphocytes, which have been shown to be capable of combining with both thyroglobulin and complexes, attach on to these molecules. The tissue damage is probably caused by the complexes, the lymphocytes, or both. Treatment of hyperthyroidism in a patient with ophthalmopathy should be cautious and with antithyroid drugs. This will reduce, though not completely eliminate, the possibility of a post-treatment exacerbation. If for some reason definitive treatment of the hyperthyroidism is essential, worsening of the ophthalmopathy may be prevented by prescribing steroids or immunosuppressive drugs at the time of surgical or radioiodine treatment. When progressive eye disease has arisen, orbital radiotherapy is a safe effective alternative to high dose corticosteroid treatment or surgical decompression.