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Hyperthyroidism is a condition in which the thyroid gland produces abnormally large amounts of hormones. The condition is most often associated with Graves' disease, but can also result from thyroid inflammation or nodules and from overtreatment with thyroid hormones. Most treatments attempt to manage the production of the thyroid, rather than cure the underlying cause of the condition. Drug treatment with antithyroid drugs can successfully alter the production of the thyroid, and is used mainly to control the condition in hopes of a remission of the underlying cause. Radioiodine treatment is the most effective long-term manner of controlling hyperthyroidism, especially in people who do not respond to drug therapy. A thyroidectomy should be seen only as a last resort.

Graves' ophthalmopathy in patients with Graves' disease may result from autoimmune attacks on eye tissues and overproduction of glycosaminoglycans, or polysaccharides. Graves' ophthalmopathy is a complication of hyperthyroid disease characterized by gritty sensations, blurred vision, increased tearing, light sensitivity, double vision, and pressure in the eye orbit, or eye cavity. Studies have linked the syndrome to several immune system components. Current theory suggests that T-cells directed against antigens on thyroid cells also recognize these antigens on orbital cells leading to an autoimmune response in connective eye tissue. As a result, glycosaminoglycan accumulates and connective tissue volume increases. Graves' ophthalmopathy occurs in 25% to 50% of Graves' disease patients and is not preventable. It is usually treated during the late stages with corticosteroids, radiotherapy, or surgery, depending on the severity of the disease.

Older patients with Graves' hyperthyroidism who are treated with iodine-131 may have an increased risk of developing the eye disorders typical of Graves' ophthalmopathy, especially if they have elevated levels of T3, one of the thyroid hormones. Of 168 patients with Graves' hyperthyroidism, 54 patients between 20 and 34 years old were treated either with the drug methimazole for 18 months or with partial removal of the thyroid. The remaining 114 patients between 35 and 55 years old were treated with methimazole, surgery or iodine-131. The younger patients developed ophthalmopathy at the same rate regardless of which treatment they received. The older patients who received iodine-131 were more likely to develop ophthalmopathy than the others. Those receiving iodine-131 who had elevated T3 levels were almost six times more likely to develop ophthalmopathy.

Graves' ophthalmopathy, a protrusion of the eyeballs as a consequence of a thyroid condition, can be successfully treated with steroids or radiation to the orbit (socket); however, surgery may still be necessary for rehabilitation of the eye. This surgery is best performed after the eye condition is stable. The final stage of surgical rehabilitation usually involves lengthening of the eyelid. There are different techniques used to treat eyelid retraction. Use of scleral tissue as a graft is generally accepted for correction of lower lid retraction, and its use for upper lid retraction has been suggested. The sclera is the opaque membrane covering the posterior five sixths of the eyeball; with the cornea it makes up the outer tunic of the eye. An evaluation was undertaken of the use of scleral grafts in 62 patients with Graves' disease. There were 78 upper lids lengthened and 50 lower lids. Ninety percent of the lower lids were successfully repaired after one operation. Only 50 percent of the operated upper lids achieved good or acceptable result after one operation. This percentage increased to 75 after the second operation and to 77 percent after the third. The authors conclude that use of scleral grafts to lengthen the upper lid is not a significant improvement over the other, simpler techniques. Scleral implant in the lower lid is very effective, however. (Consumer Summary produced by Reliance Medical Information, Inc.)

A case history is presented to illustrate the treatment of a large goiter (enlarged thyroid gland) in a fetus, first detected in an ultrasound examination at 28 weeks' gestation. Such a condition can result in serious complications during labor and at delivery, including the possibility of asphyxia if the goiter obstructs the baby's airway. The mother had Graves' disease (a condition associated with increased levels of thyroid hormone and goiter) and had become pregnant against medical advice. The patient was receiving drug treatment (propylthiouracil) during pregnancy, but the fetal goiter continued to grow. After fetal blood tests revealed that the goiter was the result of hypothyroidism (insufficient thyroid hormone), caused by the mother's thyroid medication, thyroid hormone was injected into the amniotic fluid. This was done weekly for three weeks, and the infant was delivered at 38 weeks' gestation with an only slightly enlarged thyroid. Thyroid studies on the infant were normal, and no complications were noted. A discussion is presented of fetal hypo- and hyperthyroidism, either of which can result from drug treatment of maternal hyperthyroidism. Recent developments in prenatal diagnostic approaches allow sampling of fetal blood from the umbilical cord; if thyroid hormone levels abnormal, treatment should be given directly to the fetus because the placenta does not easily allow these hormones to pass through from the mother's blood. (Consumer Summary produced by Reliance Medical Information, Inc.)

Graves' disease, an endocrine disorder also known as toxic goiter, is characterized by hyperthyroidism, or excess secretion of thyroid hormone. Patients with Graves' disease often have a typical appearance with an enlarged thyroid gland and exophthalmos (marked protrusion of the eyeballs). Imbalanced movements of the eye, resulting in diplopia (double vision), may also affect patients with Graves' disease. The active, inflammatory phase of the disease may be treated by steroids or radiotherapy. Subsequently, surgical treatment may correct the imbalance of the muscles that move the eye, but surgery fails in about 10 percent of patients. A study was undertaken to determine if duration of eye disease, or prior treatment (such as medication, radiation therapy or orbital decompression) influence surgical outcome. Thirty-eight patients with stable Graves' disease who underwent extraocular muscle surgery were reviewed. The average age of patients was 54.5 years; there were 10 men and 28 women. Nine patients had been treated with immune suppressive medication (prednisone, or cyclosporin); 12 received orbital radiation; and 13 had undergone previous decompression of the orbit (the bony cavity in the skull containing the eye). Surgical outcome was evaluated three months after surgery. Double vision was corrected after one operation in 27 patients (71 percent), and after more than one operation in seven patients (18 percent). However, double vision was not corrected in four patients (11 percent). There was no significant difference in prior treatment or duration of eye disease among patients who had correction after one operation, those who required more than one operation, or those who did not respond to surgical intervention. Prior treatment does not appear to affect the outcome of surgery in Graves' ophthalmic disease. (Consumer Summary produced by Reliance Medical Information, Inc.)

Graves' disease or hyperthyroidism is an endocrine condition in which excessive quantities of thyroid hormones are secreted into the bloodstream. As a result of this condition the patient's metabolic rate is increased and many adverse symptoms occur. Typical of Graves' disease is a group of pathologies of the eye (ophthalmopathy) including exophthalmos (bulging of the eyes) and a large increase in the size of the muscles which move the eyeball. The latter effect may limit the range of motion of the eye muscles. It remains unclear whether the ophthalmopathy of Graves' disease is directly related to Graves' disease or is a distinct and separate disease process. Ophthalmopathy may either predate or follow the onset of other symptoms of Graves' disease and it may persist following the restoration of normal levels of thyroid hormones that results from successful treatment. This study compares the effects of prednisone, an important anti-inflammatory corticosteroid, and cyclosporine, an immunosuppressive drug, in treating the ophthalmopathy of Graves' disease. One possible cause of this condition is an autoimmune reaction in which the body's own immune system is directed against the tissues of the eye, particularly the extrinsic muscles. Cyclosporine is an important immunosuppressive drug that has been used successfully to treat the serious immune reactions that occur following organ transplantation. This study examines the effects of these drugs on 36 previously untreated patients with severe Graves' ophthalmopathy (18 patients assigned to each group). The severity of eye disease was graded on a clinical scale before, during and after the various treatments. Following 12 weeks of treatment improvements were found in 11 of the 18 patients treated with prednisone, which was statistically better than the improvements in 4 of 18 patients treated with cyclosporine alone. Only patients treated with prednisone improved eye evaluation scores, visual acuity, and eye-movement. Patients who failed to respond to either medication after 12 weeks were given both drugs; some improvement was found in these patients who had not responded to single drug treatment.

Graves' disease or hyperthyroidism is an endocrine condition in which excessive quantities of thyroid hormones are secreted into the bloodstream. As a result of this condition, the patient's metabolic rate is increased and many adverse symptoms occur. Typical of Graves' disease is a group of pathologies of the eye (ophthalmopathy) including exophthalmos (bulging of the eyes) and a large increase in the size of the muscles which move the eye ball. The latter effect may limit the range of motion of the eyes. It remains unclear whether the ophthalmopathy of Graves' disease is directly related to Graves' disease or a distinct and separate disease process. Ophthalmopathy may either predate or follow the onset of other symptoms of Graves' disease and it may persist following the restoration of normal levels of thyroid hormones that results from successful treatment. The present study examines the ability of corticosteroids, important anti-inflammatory drugs, to prevent the progression of ophthalmopathy of Graves' disease. The study included 56 patients who had slight or no ophthalmopathy, and no progression of this condition during the three months before treatment of their underlying hyperthyroidism. All patients were treated with radioiodine to reduce their hyperthyroidism, and half the patients also received prednisone, a corticosteroid medication. Fifty-six percent of the patients not given prednisone had a significant increase in the degree of ophthalmopathy following the radioiodine procedure. In the other group, corticosteroids prevented the progression of eye disease in all patients and actually improved the pre-existing ophthalmopathy of 52 percent of patients. In patients with Graves' disease, short-term treatment with corticosteroids, administered simultaneously with radiotherapy, is recommended, particularly in patients with eye difficulties prior to radioiodine treatment.

Graves' disease patients may be at lower risk of developing eye disorders when treated with drugs rather than radioactive iodine. Graves' disease is a type of hyperthyroidism in which some patients develop bulging of the eyes, eyelid swelling, and other changes, sometimes following treatment. The natural course of Graves'-associated eye problems is not fully understood, although genetic factors, smoking, and treatment with radioactive iodine may be related. Methimazole is an antithyroid drug that does not appear to promote eye problems, and may be better for high-risk patients.

Most patients with Graves' hyperthyroidism develop some degree of eye abnormalities, including protrusion of the eye (exophthalmos) and enlarged eye muscles. A recent study indicates that these complications may be caused by some of the treatments used in Graves' disease, such as iodine-131 or anti-thyroid drugs. The incidence of eye abnormalities, or ophthalmopathy, was higher in older patients who were treated with iodine-131, and the abnormalities were more severe. However, the patients treated with iodine-131 were hypothyroid, and may have had high blood levels of thyrotropin. Excessive levels of thyrotropin could activate immune cells that stimulate the growth of connective tissue cells around the eye, causing it to enlarge. In addition, iodine-131 may cause an autoimmune condition in which the body produces antibodies against the thyroid as well as the eye. Individuals who will be receiving iodine-131 therapy can be treated with thyroxine to reduce their thyrotropin levels, or they can be given anti-thyroid drugs instead of iodine-131.

Graves' disease, an endocrine disorder also known as toxic goiter, is characterized by hyperthyroidism and a typical appearance of an enlarged thyroid gland and exophthalmos (marked protrusion of the eyeballs). Another sign of Graves ophthalmopathy (eye disease) is retraction of the upper eyelid. Although most signs of Graves' ophthalmopathy are related to inflammation of the muscles of eye movement, the cause of lid retraction is not known. One hypothesis is that hypertrophy of the individual fibers of the eyelid muscle (levator/rectus muscles control opening and closing of the lids) contributes to enlargement of the levator muscle causing ''hyperfunction'' of the muscle and retraction of the eyelid. If this is true there should be a correlation between the eyelid levator muscle volume and the degrees of lid retraction and lid lag. A study was undertaken to determine the possible pathophysiological causes of this lid retraction in patients with Graves' disease. Computed tomographic scans of the orbit (cavity in the skull that contains the eye) of 152 eyes of 76 patients with Graves' ophthalmopathy were reviewed. The volume of levator muscles was determined. Lid retraction and lid lag experienced by the patients was measured. The lid retraction/lag did not correlate with the lid muscle volume, and did not correlate with the limitation of vertical eye movements. These findings do not support the hypothesis that muscle hypertrophy causes lid retraction/lag. The authors suggest that these abnormalities of Graves' ophthalmopathy may be related to adherence of the muscles to adjacent tissue. (Consumer Summary produced by Reliance Medical Information, Inc.)

Patients with Graves' disease experience seemingly unrelated health problems including pathological changes of the eye, particularly of the external muscles which move the eye, the extraocular muscles. At some time these patients usually experience episodes of increased thyroid functioning, hyperthyroidism, that result in an increase in circulating thyroid hormones. Accumulation of a fluid can also occur on the tibia (leg bone), and clubbing or other bony changes of the fingers can also occur, although the latter effects are rare. The disease process can be mysterious to the clinician because so little is known about this thyroid pathology and changes of the extraocular muscles, soft tissue, skin and bone. Approximately 40 percent of patients with Graves' disease develop a group of pathologies of the eye (ophthalmopathy) including exophthalmos (bulging of the eyes) and a large increase in the size of the muscles which move the eyeball (extrinsic eye muscles). The latter effect may limit the range of motion of the eyes. Two articles in this issue of the Journal discuss the treatment of Graves' disease as a means of improving ophthalmopathy. These papers describe the experience of patients following radioactive iodine treatments which are used to destroy thyroid tissue and decrease hyperthyroidism. The articles discuss various treatments used to arrest the ophthalmopathy of Graves' disease, including prednisone and cyclosporine, an immunosuppressive drug. The results show that current treatments are not uniformly effective, nor are they without significant side effects. Fortunately most patients do not require such aggressive treatments, but for those who do, the use of prednisone or surgery (orbital decompression, in which fat is removed from the eye socket) is recommended as treatment for ophthalmopathy of Graves' disease.