Endocrine ophthalmopathy - causes, symptoms, diagnosis and treatment

Endocrine ophthalmopathy (thyroid ophthalmopathy, Graves ophthalmopathy, autoimmune ophthalmopathy) - an autoimmune process that occurs with a specific lesion retrobulbar tissue, and is accompanied by exophthalmos and ophthalmoplegia varying severity. For the first time the disease has been described in detail K. Graves in 1776

Endocrine ophthalmopathy - issues of interest to clinical endocrinology and ophthalmology. Endocrine ophthalmopathy affects about 2% of the total population, while among women the disease develops in 5-8 times more often than men. Age dynamics is characterized by two peaks manifestation of Graves' eye disease - in the 40-45 years and 60-65 years. Endocrine ophthalmopathy may also develop in childhood, often in girls first and second decade of life.

thyrotoxicosis (60-90%), hypothyroidism (08-15%), autoimmune thyroiditis (3.3%), euthyroid status (58-25%).

Factors that trigger endocrine ophthalmopathy, is still not completely understood. In the role of triggers may make respiratory infections, small doses of radiation, sun exposure, smoking, heavy metal salts, stress, autoimmune diseases (diabetes, etc.), Inducing a specific immune response. Endocrine ophthalmopathy marked association with some antigens HLA-system: HLA-DR3 HLA-DR4 HLA-B8. Soft shaped endocrine ophthalmopathy more common among young adults, the disease is characterized by severe for the elderly.

It is assumed that due to the spontaneous mutation of the T-cells begin to interact with the receptor membranes eye muscle cells and cause specific changes in them. Autoimmunity T lymphocytes and the target cells is accompanied by the release of cytokines (interleukin, tumor necrosis factor, γ-interferon, transforming growth factor-b, platelet-derived growth factor, insulin-like growth factor 1), which induce the proliferation of fibroblasts, collagen and glycosaminoglycan production. The latter, in turn, contribute to the binding of water, the development of edema and retrobulbar tissue volume increase. Edema and infiltration of the orbit tissue eventually replaced by fibrosis, causing exophthalmos becomes irreversible.

corneal ulcers, stagnant in the fundus, pains in the orbit and venous stasis. The clinical course of edematous exophthalmos isolated phase compensation, and decompensation subcompensation.

When endocrine myopathy occurs weakness often direct the eye muscles, resulting in double vision, inability to exhaust the eye outwards and upwards, squint, the deviation of the eyeball downward. Due to the hypertrophy of the eye muscles progressively increases its collagen degeneration.

To indicate the severity of endocrine ophthalmopathy classification VG Baranov commonly used in Russia, according to which emit 3 degrees endocrine ophthalmopathy.

The criteria for endocrine ophthalmopathy 1 degree are: unexpressed exophthalmos (15.9 mm), mild swelling of the eyelids. conjunctival tissues while intact, the function of the eye muscles is not broken.

Endocrine ophthalmopathy is characterized by 2 degrees moderate, exophthalmos (17.9 mm), a significant swelling of the eyelids, severe swelling of the conjunctiva, periodic double vision.

When endocrine ophthalmopathy Grade 3 revealed pronounced signs of exophthalmos (20.8 mm or more), diplopia resistant nature, the inability to complete closing the eyelids, corneal ulceration, the phenomenon of optic nerve atrophy.

conjunctivitis and iridocyclitis. Inflammatory infiltration of the lacrimal gland is aggravated by dry eye syndrome.

In marked exophthalmos may occur compression of the optic nerve, leading to his subsequent atrophy. Exophthalmos with endocrine ophthalmopathy should be differentiated from psevdoekzoftalmom observed with high myopia, orbital cellulitis (cellulitis of the orbit), tumors (hemangiomas and Kaposi's orbit, meningiomas, and others.).

Mechanical eyeballs limited mobility increases in intraocular pressure and the development of so-called psevdoglaukomy; in some cases, develop retinal vein occlusion. Involvement of the eye muscles is often accompanied by the development of strabismus.

endocrinologist and an ophthalmologist with the implementation of complex instrumental and laboratory procedures.

Endocrinological examination is aimed at clarifying the thyroid function and includes the study of thyroid hormones (free T4 and T3), antibodies to thyroid tissue (AT thyroglobulin and thyroid peroxidase Am), holding ultrasound of the thyroid gland. In the case of thyroid nodules larger than 1 cm, shows the implementation of needle biopsy.

Ophthalmologic examination in endocrine ophthalmopathy aims to clarify the visual function and imaging of the orbit structures. The function block includes visometry, perimetry, the study of convergence, electrophysiological studies. Biometric researches of an eye (exophthalmometer, squint angle measurement) allow us to determine the height of an emergence and the degree of deviation of the eyeballs.

To exclude the development of optic neuropathy produced fundus examination (ophthalmoscopy); to assess the state structures of the eye - biomicroscopy; to identify ocular hypertension performed tonometry. Imaging techniques (ultrasound, CT, MRI of the orbits) differentiate endocrine ophthalmopathy from the retrobulbar tissue tumors.

When endocrine ophthalmopathy is extremely important to the immune system of the patient examination. Changes in cellular and humoral immunity in endocrine ophthalmopathy is characterized by a decrease in the number of CD3 + T-lymphocytes, the change in the ratio of CD3 + lymphocytes and, a decrease in the number of CD8 + T-cynpeccopov; an increase in IgG levels, antinuclear antibodies; increasing titer of antibodies to TG, TPO, AMAb (eye muscles), second colloid antigen. According to the testimony performed a biopsy of affected eye muscles.

retrobulbar injection. With the threat of vision loss carried methylprednisolone pulse therapy, radiotherapy orbits. The use of glucocorticoids is contraindicated in gastric ulcer or duodenal ulcer, pancreatitis, thrombophlebitis, arterial hypertension, bleeding disorders, psychiatric diseases and cancer. The methods of complementary immunosuppressive therapy, are plasmapheresis, hemosorbtion, immunoadsorption, krioaferez.

In the presence of thyroid dysfunctions conducted its correction tirostatikov (thyrotoxicosis) or thyroid hormone (hypothyroidism). If unable to stabilize thyroid function may need to perform total thyroidectomy followed by HRT.

Symptomatic therapy for endocrine ophthalmopathy to normalize metabolic processes in the tissues and neuromuscular transmission. For this purpose, appointed aktovegina injection, neostigmine, instillation of drops, ointments and gels laying, intake of vitamins A and E. From physiotherapy methods for endocrine ophthalmopathy used electrophoresis Lydasum or aloe, magnetic region on the orbit.

Possible surgical treatment of endocrine ophthalmopathy includes three types of eye operations: decompression of the orbit, extraocular muscle surgery, surgery on the eyelids. Decompression of the orbit aimed at increasing the volume of the orbit and is indicated for progressive optic neuropathy, marked proptosis, corneal ulceration, subluxation of the eyeball, and others. Situations. Decompression of the orbit (orbitotomiya) is achieved by resection of one or more of its walls, removal of retrobulbar fat.

Surgical interventions on the eye muscles are shown in the development of persistent painful diplopia, paralytic strabismus, if it can not be 'corrected prismatic glasses.

eyelid operations represent a large group of various plastic and functional interventions, the choice of which is dictated by which developed violation (retraction, spastic volvulus, lagophthalmos, prolapse of the lacrimal gland, hernia with prolapse of orbital fat, etc.).

Forecast endocrine ophthalmopathy

In 1-2% of cases there is a particularly severe course of endocrine ophthalmopathy, which leads to severe visual complications or residual effects. Timely medical intervention allows for induced remission and avoid the serious consequences of the disease. The result of treatment in 30% of patients is clinical improvement, 60% - to stabilize the flow of the endocrine ophthalmopathy, 10% - to further disease progression.