Autoimmune ophthalmopathy. Endocrine ophthalmopathy common in violation of hormone production: treatment of an unpleasant symptom and eye damage Autoimmune ophthalmopathy

- this is an organ-specific progressive lesion of the soft tissues of the orbit and the eye, which develops against the background of an autoimmune pathology of the thyroid gland. The course of endocrine ophthalmopathy is characterized by exophthalmos, diplopia, swelling and inflammation of eye tissues, limited mobility of the eyeballs, changes in the cornea, optic disc, intraocular hypertension. Diagnosis of endocrine ophthalmopathy requires an ophthalmological examination (exophthalmometry, biomicroscopy, CT of the orbit); studies of the state of the immune system (determination of the level of Ig, Ab to TG, Ab to TPO, antinuclear antibodies, etc.), endocrinological examination (T4 St., T3 St., ultrasound of the thyroid gland, puncture biopsy). Treatment of endocrine ophthalmopathy is aimed at achieving a euthyroid state; may involve drug therapy or removal of the thyroid gland.

ICD-10

H57.9 E05.0

General information

Endocrine ophthalmopathy (thyroid ophthalmopathy, Graves' ophthalmopathy, autoimmune ophthalmopathy) is an autoimmune process that occurs with a specific lesion of retrobulbar tissues and is accompanied by exophthalmos and ophthalmoplegia of varying severity. The disease was first described in detail by K. Graves in 1776.

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

The reasons

Endocrine ophthalmopathy occurs against the background of primary autoimmune processes in the thyroid gland. Eye symptoms may appear simultaneously with the clinic of thyroid lesions, precede it, or develop in the long term (on average, after 3-8 years). Endocrine ophthalmopathy may be accompanied by thyrotoxicosis (60-90%), hypothyroidism (0.8-15%), autoimmune thyroiditis (3.3%), euthyroid status (5.8-25%).

The factors initiating endocrine ophthalmopathy have not yet been fully elucidated. The triggers can be:

• respiratory infections,
• small doses of radiation
• insolation,
• smoking,
• heavy metal salts,
• stress,
• autoimmune diseases (diabetes mellitus, etc.) that cause a specific immune response.

An association of endocrine ophthalmopathy with some antigens of the HLA system was noted: HLA-DR3, HLA-DR4, HLA-B8. Mild forms of endocrine ophthalmopathy are more common among young people, severe forms of the disease are typical for the elderly.

Pathogenesis

It is assumed that due to spontaneous mutation, T-lymphocytes begin to interact with the receptors of the membranes of eye muscle cells and cause specific changes in them. The autoimmune reaction of T-lymphocytes and target cells is accompanied by the release of cytokines (interleukin, tumor necrosis factor, γ-interferon, transforming growth factor b, platelet growth factor, insulin-like growth factor 1), which induce fibroblast proliferation, collagen formation and the production of glycosaminoglycans. The latter, in turn, contribute to the binding of water, the development of edema and an increase in the volume of retrobulbar tissue. Edema and infiltration of the tissues of the orbit are replaced by fibrosis over time, as a result of which exophthalmos becomes irreversible.

Classification

In the development of endocrine ophthalmopathy, there is a phase of inflammatory exudation, an infiltration phase, which is replaced by a phase of proliferation and fibrosis. Taking into account the severity of eye symptoms, three forms of endocrine ophthalmopathy are distinguished:

1. Thyrotoxic exophthalmos. It is characterized by slight true or false protrusion of the eyeballs, retraction of the upper eyelid, lag of the eyelid when lowering the eyes, tremor of the closed eyelids, eye glare, convergence insufficiency.
2. Edematous exophthalmos. They speak of edematous exophthalmos when the eyeballs are 25–30 mm long, with pronounced bilateral edema of the periorbital tissues, diplopia, and a sharp limitation in the mobility of the eyeballs. Further progression of endocrine ophthalmopathy is accompanied by complete ophthalmoplegia, non-closure of the palpebral fissures, conjunctival chemosis, corneal ulcers, congestion in the fundus, pain in the orbit, venous stasis. In the clinical course of edematous exophthalmos, the phases of compensation, subcompensation and decompensation are distinguished.
3. endocrine myopathy. With endocrine myopathy, there is weakness more often than the rectus oculomotor muscles, leading to diplopia, the impossibility of moving the eyes outwards and upwards, strabismus, deviation of the eyeball downwards. As a result of hypertrophy of the oculomotor muscles, their collagen degeneration progressively increases.

To indicate the severity of endocrine ophthalmopathy in Russia, the classification of V. G. Baranov is usually used, according to which 3 degrees of endocrine ophthalmopathy are distinguished.

• The criteria for endocrine ophthalmopathy of the 1st degree are: unexpressed exophthalmos (15.9 mm), moderate swelling of the eyelids. The tissues of the conjunctiva are intact, the function of the oculomotor muscles is not impaired.
• Endocrine ophthalmopathy of the 2nd degree is characterized by moderately pronounced exophthalmos (17.9 mm), significant eyelid edema, severe conjunctival edema, and periodic doubling.
• With endocrine ophthalmopathy of the 3rd degree, pronounced signs of exophthalmos (20.8 mm or more), persistent diplopia, impossibility of complete closure of the eyelids, corneal ulceration, and optic nerve atrophy are detected.

Symptoms of endocrine ophthalmopathy

Early clinical manifestations of endocrine ophthalmopathy include transient sensations of "sand" and pressure in the eyes, lacrimation or dry eyes, photophobia, swelling of the periorbital region. In the future, exophthalmos develops, which at first is asymmetric or unilateral.

At the stage of advanced clinical manifestations, these symptoms of endocrine ophthalmopathy become permanent; to them is added a noticeable increase in the protrusion of the eyeballs, an injection of the conjunctiva and sclera, swelling of the eyelids, diplopia, and headaches. The impossibility of complete closure of the eyelids leads to the formation of corneal ulcers, the development of conjunctivitis and iridocyclitis. Inflammatory infiltration of the lacrimal gland is exacerbated by dry eye syndrome.

Complications

With severe exophthalmos, compression of the optic nerve may occur, leading to its subsequent atrophy. Mechanical restriction of the mobility of the eyeballs leads to an increase in intraocular pressure and the development of the so-called pseudoglaucoma; in some cases, retinal vein occlusion develops. Involvement of the eye muscles is often accompanied by the development of strabismus.

Diagnostics

The diagnostic algorithm for endocrine ophthalmopathy involves an examination of the patient by an endocrinologist and an ophthalmologist with a set of instrumental and laboratory procedures.

1.Endocrinological examination is aimed at clarifying the function of the thyroid gland and includes the study of thyroid hormones (free T4 and T3), antibodies to thyroid tissue (Ab to thyroglobulin and Ab to thyroperoxidase), ultrasound of the thyroid gland. In case of detection of thyroid nodules with a diameter of more than 1 cm, a puncture biopsy is indicated.

2.Functional ophthalmological examination in endocrine ophthalmopathy aims to clarify the visual function. The functional block includes:

• biometric studies of the eye (exophthalmometry, measurement of the angle of strabismus) - allow you to determine the height of the protrusion and the degree of deviation of the eyeballs

3.Imaging methods aimed at morphological assessment of eye structures. Includes the following studies:

• examination of the fundus (ophthalmoscopy) is performed to exclude the development of optic neuropathy
• biomicroscopy - to assess the condition of the structures of the eye
• tonometry - performed to detect intraocular hypertension
• Ultrasound, MRI, CT of the orbits) make it possible to differentiate endocrine ophthalmopathy from tumors of the retrobulbar tissue.

4. Immunological examination. In endocrine ophthalmopathy, it is extremely important to examine the patient's immune system. Changes in cellular and humoral immunity in endocrine ophthalmopathy are characterized by a decrease in the number of CD3 + T-lymphocytes, a change in the ratio of CD3 + and lymphocytes, a decrease in the number of CD8 + T-cynpeccors; an increase in the level of IgG, antinuclear antibodies; an increase in Ab titer to TG, TPO, AMAb (eye muscles), the second colloidal antigen. According to indications, a biopsy of the affected oculomotor muscles is performed.

Exophthalmos in endocrine ophthalmopathy should be differentiated from pseudoexophthalmos observed with a high degree of myopia, orbital cellulitis (orbital phlegmon), tumors (hemangiomas and sarcomas of the orbit, meningiomas, etc.).

Treatment of endocrine ophthalmopathy

Pathogenetic therapy

Therapeutic tactics is determined by the stage of endocrine ophthalmopathy, the degree of dysfunction of the thyroid gland and the reversibility of pathological changes. All treatment options aim to achieve a euthyroid state.

1. immunosuppressive therapy. It includes the appointment of glucocorticoids (prednisolone), which have anti-edematous, anti-inflammatory and immunosuppressive effects. Corticosteroids are given orally and as retrobulbar injections. With the threat of loss of vision, pulse therapy with methylprednisolone, x-ray therapy of the orbits is performed. The use of glucocorticoids is contraindicated in gastric or duodenal ulcers, pancreatitis, thrombophlebitis, arterial hypertension, bleeding disorders, mental and oncological diseases.
instillation of drops, laying ointments and gels, taking vitamins A and E. Of the methods of physiotherapy for endocrine ophthalmopathy, electrophoresis with lidase or aloe is used, and magnetotherapy in the area of ​​\u200b\u200borbits.

Possible surgical treatment of endocrine ophthalmopathy includes three types of ophthalmic operations:

• Orbital decompression. It is aimed at increasing the volume of the orbit and is indicated for progressive optic neuropathy, severe exophthalmos, corneal ulceration, subluxation of the eyeball, and other situations. Decompression of the orbit (orbitotomy) is achieved by resection of one or more of its walls, removal of retrobulbar tissue.
• Operations on the oculomotor muscles. Indicated in the development of persistent painful diplopia, paralytic strabismus, if it cannot be corrected with prismatic glasses.
• Operations on the eyelids. They represent a large group of various plastic and functional interventions, the choice of which is dictated by the developed disorder (retraction, spastic volvulus, lagophthalmos, lacrimal gland prolapse, hernia with prolapse of orbital fiber, etc.).

Forecast

In 1-2% of cases, a particularly severe course of endocrine ophthalmopathy is observed, leading to severe visual complications or residual effects. Timely medical intervention allows to achieve induced remission and avoid severe consequences of the disease. The result of therapy in 30% of patients is clinical improvement, in 60% - stabilization of the course of endocrine ophthalmopathy, in 10% - further progression of the disease.

Graves' endocrine or ophthalmopathy is a lesion of the muscles and retrobulbar tissues of the eyeball that occurs with autoimmune thyroid diseases. In most patients, the pathology develops with, less commonly, the cause is thyroiditis or an isolated lesion of the eye orbit is observed.

The disease leads to the development of bulging eyes, an increase in intraocular pressure, and a bifurcation of the image.

Symptoms of endocrine ophthalmopathy are most often detected in women aged 40–45 and 60–65 years. The disease can also be diagnosed in children under 15 years of age. Moreover, young people tolerate the disease easily, and elderly patients suffer from severe forms of EOP.

The main reason for the development of endocrine ophthalmopathy are autoimmune processes in the body. At the same time, the human immune system begins to perceive eye tissue as a foreign body and produce specific antibodies to thyroid-stimulating hormone receptors (AT to TSH). T-lymphocytes provoke the formation of edema, an increase in the volume of muscle fibers, an inflammatory process, and infiltration.

As inflammation subsides, healthy tissues are replaced by connective tissue, after another 1–2 years scars form, after which exophthalmos persists for life.

Endocrine ophthalmopathy can be diagnosed with the following diseases:

• thyrotoxicosis;
• autoimmune Hashimoto's thyroiditis;
• thyroid cancer;
• diabetes;
• hypothyroidism.

In 15% of patients, a euthyroid state is recorded, in which the functioning of the thyroid gland is not impaired. Provoking factors for the development of endocrine ophthalmopathy include bacterial, viral infection, radiation exposure, smoking, and stress.

Damage to the tissues of the orbit can occur during the acute course of diffuse goiter or long before its onset, in some patients the symptoms persist for several more years after the treatment (3–8 years).

Clinical signs of endocrine ophthalmopathy

With thyrotoxicosis, exophthalmos develops, characterized by protrusion of the eyeballs outward. The volume of the upper eyelid decreases, due to which the incision of the palpebral fissure increases, the patient cannot completely close his eyes. Symptoms usually worsen over 18 months.

Symptoms of endocrine ophthalmopathy:

• feeling of sand in the eyes;
• photophobia;
• lacrimation;
• with ophthalmopathy, dry eyes appear;
• diplopia - doubling of the image when looking away to the side;
• headache;
• exophthalmos - bulging eyes;
• Kocher's symptom - the appearance of a visible area of ​​\u200b\u200bthe sclera between the upper eyelid and the iris when looking down;
• strabismus;
• ophthalmopathy causes redness of the conjunctiva, sclera;
• eyelid skin pigmentation;
• rare blinking;
• the impossibility of diverting gas to the sides;
• trembling, drooping of the eyelids.

Exophthalmos in endocrine ophthalmopathy is unilateral or affects both eyes. Due to incomplete closure of the eyelids, corneal ulceration occurs, chronic conjunctivitis, iridocyclitis, and dry eye syndrome develop. With severe edema, compression of the optic nerve is observed, leading to visual impairment, atrophy of the nerve fibers. Damage to the muscles of the fundus leads to an increase in intraocular pressure, strabismus, retinal vein thrombosis is formed.

If myopathy of the oculomotor muscles develops with endocrine ophthalmopathy, then double vision occurs, the pathology has a progressive course. Such symptoms occur predominantly in men with hypothyroidism or a euthyroid state. Later, exophthalmos joins, swelling of the fiber is not observed, but the volume of the muscles increases, the patient cannot move his eyes up and down. Areas of infiltration are quickly replaced by fibrous tissues.

Symptoms of edematous exophthalmos

Edematous endocrine ophthalmopathy is characterized by bilateral eye damage, the pathology is not observed simultaneously, the interval can be up to several months. This form of the disease has 3 stages of the course:

• Compensation of ophthalmopathy develops gradually. Patients note the drooping of the upper eyelid in the first half of the day, and by the evening the condition returns to normal. As the disease progresses, retraction of the eyelid occurs, an increase in the palpebral fissure. Muscle tone increases, contracture occurs.
• Subcompensation of endocrine ophthalmopathy is accompanied by an increase in intraocular pressure, swelling of retrobulbar tissues of a non-inflammatory nature, exophthalmos, and the lower eyelid is affected by chemosis. The symptoms of bulging eyes are clearly manifested, the eyelids do not close completely, the small vessels of the sclera become tortuous and form a pattern in the form of a cross.
• The stage of decompensation of endocrine ophthalmopathy is characterized by an increase in the clinical picture. Due to swelling of the fiber, the eye becomes motionless, the optic nerve is damaged. The cornea ulcerates, keratopathy develops. Without therapy, nerve fibers atrophy, vision deteriorates due to the formation of a thorn.

Endocrine ophthalmopathy in most cases does not lead to loss of vision, but significantly worsens it due to complication of keratitis, compression neuropathy.

Classification of endocrine ophthalmopathy

Depending on the degree of manifestation of clinical symptoms, EOP is classified according to the Baranov method:

• I degree of ophthalmopathy is manifested by a slight exophthalmos less than 16 mm, there is swelling of the eyelids, sand in the eyes, dry mucous membranes, lacrimation. Violations of motor functions do not occur.
• II degree of endocrine ophthalmopathy - exophthalmos up to 18 mm, slight changes in the sclera, oculomotor muscles, sand, lacrimation, photophobia, diplopia, swelling of the eyelids.
• III degree of endocrine ophthalmopathy - bulging is pronounced up to 22 mm, incomplete closure of the eyelids, corneal ulcers, impaired eye mobility, visual impairment, symptoms of persistent diplopia are recorded.

According to the method of Brovkina, endocrine ophthalmopathy is classified into thyrotoxic, edematous exophthalmos and myopathy. Each of the stages can move into the next without timely treatment.

The international classification NOSPECS has its own characteristics.

0 class N endocrine ophthalmopathy - no symptoms.

Class 1 O - retraction of the upper eyelid.

Class 2 S endocrine ophthalmopathy - soft tissue damage:

• missing;
• minimal;
• moderate severity;
• pronounced.

Class 3 P endocrine ophthalmopathy - the presence of signs of exophthalmos:

• less than 22 mm;
• 22–25 mm;
• 25–27 mm;
• over 27 mm.

Class 4 E endocrine ophthalmopathy - damage to the oculomotor muscles:

• there are no symptoms;
• slight limitation of the mobility of the eyeballs;
• pronounced limitation of mobility;
• permanent fixation.

Class 5 D endocrine ophthalmopathy - symptoms of corneal damage:

• missing;
• moderate;
• ulceration;
• perforations, necrosis.

Grade 6 S ophthalmopathy - damage to the optic nerve:

• less than 0.65;
• 0,65–0,3;
• 0,3–0,12;

Severe include degrees starting from 3, and class 6 is diagnosed as a complicated form of endocrine ophthalmopathy.

Differential Diagnosis

To assess the state of the thyroid gland, patients take a blood test for the level of thyroid hormones, antibodies to the receptors and TPO. With endocrine ophthalmopathy, the concentration of T3 and T4 significantly exceeds the norm.

Ultrasound examination allows you to determine the size and degree of enlargement of the organ, to identify nodular formations. If large nodules larger than 1 cm in diameter are found, a fine-needle aspiration biopsy is performed.

Ophthalmological examination includes ultrasound of the orbit of the fundus, measurement of intraocular pressure, perimetry, visual acuity and visual fields. The condition of the cornea, the degree of mobility of the apple are assessed. Additionally, CT, MRI of the orbit, muscle biopsy can be prescribed.

Autoimmune ophthalmopathy is differentiated with myosthenia gravis, pseudoexophthalmos with myopia, phlegmon of the orbit, malignant tumors of the orbit, neuropathies of another etiology.

Treatment Methods

Treatment of ophthalmopathy is prescribed taking into account the severity and cause of the pathology. Apply conservative and surgical methods of therapy. Disorders of the thyroid gland are eliminated under the supervision of an endocrinologist. Patients are prescribed hormone replacement therapy or thyreostatics that suppress hypersecretion of T3, T4. With the ineffectiveness of medications, a partial or complete removal of the thyroid gland is performed.

To relieve symptoms of acute inflammation in endocrine ophthalmopathy, glucocorticoids (Prednisolone), steroids are prescribed. Cyclosporine is indicated to suppress immune processes, the drug changes the functions of T-lymphocytes, and is prescribed in the complex treatment of endocrine ophthalmopathy.

Pulse therapy is performed for neuropathies, severe inflammation. Hormones are administered intravenously in large doses over a short period of time. If after 2 days the desired result is not achieved, surgical intervention is performed.

For the treatment of endocrine ophthalmopathy, the method of retrobulbar administration of glucocorticoids is used. The drugs are injected into the upper-lower orbit to a depth of 1.5 cm. This method helps to increase the concentration of the drug directly in the affected tissues.

Endocrine ophthalmopathy, accompanied by persistent diplopia, decreased vision, inflammation, is treated with radiation therapy. X-rays help destroy fibroblasts and abnormal T-lymphocytes. A good result is achieved with early treatment of EOP with the complex use of glucocorticosteroids.

As a symptomatic therapy for endocrine ophthalmopathy, drugs that normalize metabolism (Prozerin), eye antibacterial drops, gels, vitamins A, E are prescribed. Physiotherapy procedures are carried out: magnetotherapy, electrophoresis with aloe.

Therapy for thyrotoxicosis

Conservative treatment is prescribed for a slight increase in the size of the thyroid gland without symptoms of compression of the esophagus, trachea and pronounced signs of endocrine ophthalmopathy. For patients with thyroid nodules and exophthalmos, drug therapy is prescribed before surgical treatment or the use of radioactive iodine.

A euthyroid state can be achieved 3–5 weeks after a course of thyreostatics. In 50% of cases, remission lasts up to 2 years, the rest of the patients relapse. At the same time, a high titer of antibodies to TSH is found in the blood of patients.

Thyrostatic therapy in patients with ophthalmopathy is carried out with drugs of the thionamide group:

• Timozol;
• Mercazolil.

Additionally, β-blockers are prescribed to prevent tissue conversion of thyroxine to triiodothyronine. There are 2 types of thyreostatic treatment: monotherapy or a complex combination of thyreostatics with L-thyroxine. The effectiveness of the results is assessed by the level of T3, T4, TSH indicators are not informative.

With endocrine ophthalmopathy, it is carried out by taking an active iodine molecule, which can accumulate in the tissues of the thyroid gland and cause destruction of its cells. As a result, the secretion of thyroid hormones decreases, followed by the development of hypothyroidism and the appointment of thyroxine replacement therapy.

Surgical intervention is indicated for large thyroid glands, compression of the esophagus, trachea, abnormal location of the goiter, and ineffectiveness of conservative treatment. A partial excision of the organ is carried out or the thyroid gland is completely removed.

Surgical treatment of endocrine ophthalmopathy

The indication for surgery is:

• ineffectiveness of conservative therapy;
• compression optic neuropathy;
• subluxation of the eyeball;
• pronounced exophthalmos;
• symptoms of severe corneal damage.

Decompression of the orbits in endocrine ophthalmopathy prevents the death of the eye, increases the volume of the orbits. During the operation, a partial removal of the walls of the orbit and the affected tissue is performed, which makes it possible to slow down the progression of the disease, reduce intraocular pressure, and reduce exophthalmos.

Orbital decompression is carried out in several ways:

• The transantral method consists in removing the inferior, medial, or outer wall of the orbit. A complication of the operation may be a violation of sensitivity in the periorbital region.
• Transfrontal decompression is performed by excision of the anterior wall of the orbit with access through the frontal bone. As a result, symptoms of exophthalmos decrease, pressure decreases. With this method, there is a risk of bleeding, damage to brain structures, liquorrhea, meningitis.
• Internal DO is the removal of retrobulbar tissue up to 6 mm³. This method is used in the normal state of soft tissues (ophthalmopathy class 2 Sa), which is determined by the results of CT, MRI.
• Transendmoidal endoscopic decompression - removal of the medial wall of the orbit to the sphenoid sinus. As a result of the operation, the retrobulbar tissues are displaced to the region of the ethmoid labyrinth, the position of the eyeball is normalized, it is possible to achieve regression of exophthalmos.

Surgical correction of the oculomotor muscles in case of strabismus, diplopia is carried out during the period of stabilization of the patient's condition. To achieve the desired result, to improve binocular vision in patients with ophthalmopathy, several operations may be required. To eliminate cosmetic defects, surgical lengthening of the eyelids is performed, injections of Botuloxin, subconjunctival Triamcinolone are made to reduce retraction and completely close the eye.

Lateral tarsorrhaphy (suturing the edges of the eyelids) in endocrine ophthalmopathy helps to correct the upper and lower eyelids, but the effectiveness of this procedure is less than DO. Mueller tenotomy allows for eyelid drooping. The final stage is blepharoplasty and dacryopexy of the lacrimal openings.

Forecast

The effectiveness of the treatment of endocrine ophthalmopathy depends on how quickly the medications were prescribed. Proper treatment of the disease in the early stages can prevent the progression and development of complications, and a protracted remission can be achieved. Deterioration of the condition is noted only in 5% of patients.

People suffering from symptoms of endocrine ophthalmopathy are advised to give up bad habits, wear dark glasses, use eye drops to protect the cornea from drying out. Patients should be registered with a dispensary, regularly examined by an endocrinologist and an ophthalmologist, take thyreostatics or replacement therapy drugs prescribed by a doctor. Once every 3 months, you should donate blood to the level of thyroid hormones.

Endocrine ophthalmopathy is characterized by damage to the retrobulbar tissues of the eye orbits with varying degrees of intensity. Symptoms of pathology most often develop with thyrotoxicosis of the thyroid gland, caused by hypersecretion of thyroid hormones against the background of autoimmune processes. Treatment should be carried out comprehensively, including the use of thyreostatics, glucocorticoids, steroids, immunosuppressants. With severe optic neuropathy, exophthalmos, surgical decompression of the eye orbits is performed.

Endocrine ophthalmopathy (EOP, Graves' ophthalmopathy, thyroid-associated orbitopathy) is an autoimmune process that often occurs against the background of thyroid diseases, with damage to the orbital and periorbital tissues, which leads to their degenerative changes. EOP precedes, accompanies or is one of the symptoms of systemic complications in violation of the hormonal level of the thyroid gland. In some cases, EOP manifests itself in conjunction with myasthenia gravis, vitiligo, Addison's disease, pernicious anemia and yersiniosis. There is a clear relationship between the risk of occurrence and severity of thyroid-associated orbitopathy with smoking. Radioiodine therapy used in the treatment of thyroid pathologies often contributes to the manifestation of EOP and its progression.

Causes of endocrine ophthalmopathy

There is no consensus on the reasons for the development of the EOP to this day. However, most opinions agree that some changes in the tissues of the orbit cause a pathological immune response in the body, as a result of which antibodies penetrate into these tissues, which causes inflammation and swelling, and, after 1 or 2 years, scarring of the surface. According to one hypothesis, the cells of the thyroid tissue, as well as the retroorbital space, have common fragments of antigens (epitopes), which, due to some reasons, begin to be perceived by the immune system as foreign. As an argument, the authors put forward the fact that EOP in 90% of cases is accompanied by diffuse toxic goiter, when euthyroidism is reached, the severity of eye symptoms decreases, and the level of antibodies in this combination of diseases to the thyroid-stimulating hormone receptor is high. According to another version, EOP appears to be an independent disease with a primary lesion of the orbital tissues. An argument in favor of this theory is the absence of thyroid dysfunction in approximately 10% of EOP cases.

And yet, the cause of EOP is not in the defeat of the thyroid gland, therefore, the regulation of its functions is not able to reverse the development of this disease. Most likely, the autoimmune process can affect the endocrine gland along with the muscles of the eye and the fiber of the orbit. True, the restoration of the natural hormonal level of the thyroid gland can alleviate the course of endocrine ophthalmopathy, although in some cases this does not help to slow down its progression.

Most patients with EOP report a hyperthyroid state, but euthyroidism may occur in 20% of cases. In addition, sometimes pathologies are even detected, accompanied by a decrease in the level of thyroid hormones, such as Hashimoto's thyroiditis or thyroid cancer. Eye symptoms, in the presence of hyperthyroidism, usually develop within 1.5 years.

The incidence averages approximately 16 cases in women and 2.9 cases in men out of 100,000 people in the population. Thus, in women, the predisposition to this disease is much higher, but more severe cases have been noted in men. The disease manifests itself by the age of 30-50 years, and the severity of manifestations usually increases with age (after 50 years).

Manifestations of endocrine ophthalmopathy

The symptom complex of EOP, as a rule, is due to the presence of concomitant pathologies of the thyroid gland, which add their characteristic manifestations. At the same time, ocular manifestations of endocrine ophthalmopathy are considered to be retraction of the eyelid (tight upwards), a feeling of pressure and pain, impaired color perception, dry eyes, exophthalmos (anterior protrusion of the eyeball), conjunctival edema (chemosis), periorbital edema, restriction of movements of the eyeball, leading to to significant functional as well as cosmetic disorders. These symptoms may be unilateral or occur in both eyes. Their manifestation and severity are directly related to the stage of the disease.

Many symptoms of EOP are named after the authors who first described them, as follows:

• The Gifferd-Enros symptom is eyelid edema;
• Dalrymple's symptom - retraction of the eyelid, accompanied by a wide opening of the palpebral fissures;
• Kocher's symptom is the visibility of the area of ​​the sclera between the iris and the upper eyelid when looking down;
• Stelwag's symptom - rare blinking;
• The Mobius-Graefe-Minz symptom is a lack of coordination in the movements of the eyeballs;
• Pohin's syndrome - bending of the eyelids when closing;
• Rodenbach's symptom is a trembling of the eyelids;
• Jellinek's symptom - pigmentation of the eyelids.

The vast majority of cases of endocrine ophthalmopathy do not lead to loss of vision, but they cause its deterioration due to the development of diplopia, keratopathy, compression optic neuropathy.

Diagnostics

The pronounced clinical picture of EOP does not require special studies for its diagnosis, an ophthalmological examination is sufficient. It includes: the study of optical media, visometry, perimetry, checking color vision and consistency of eye movements. The degree of exophthalmos is measured with a Hertel exophthalmometer. In case of difficulties, as well as in order to assess the state of the motor muscles of the eye and tissues in the retrobulbar region, ultrasound, MRI or CT can be prescribed. With a combination of EOP and thyroid pathology, the hormonal status is examined (laboratory studies of the level of total T3, T4 and associated T3, T4 and TSH). The presence of EOP can also be indicated by an increase in the excretion of glycosaminoglycans in the urine, the presence of antithyroglobulin or acetylcholinesterase antibodies in the blood, exophthalmogenic Ig and ophthalmopathic Ig, alpha-galactosyl-AT, AT to the microsomal fraction, AT to the eye protein.

Classification

Today, there are several classifications for the EOP. The simplest one distinguishes two types of the disease, which, however, do not exclude each other. The first type includes EOP, accompanied by minimal signs of restrictive myopathy and inflammation, the second - EOP, accompanied by their significant manifestations.

Foreign experts use the NOSPECS classification.

In Russia, it is customary to apply the Baranov classification.

Degrees

• 1 Exophthalmos is insignificant (15.9 ± 0.2 mm), the eyelids are swollen, periodically there is a feeling of "sand", occasionally lacrimation. There were no disturbances in the function of the motor muscles of the eyes.
• 2 (moderate severity) Moderate exophthalmos (17.9 ± 0.2 mm), there are mild changes in the conjunctiva, mild or moderate extraocular muscle dysfunction, persistent feeling of "sand", unstable diplopia, lacrimation, photophobia.
• 3 (severe) Exophthalmos is pronounced (22.2 ± 1.1 mm), there is a violation of the closure of the eyelids, persistent diplopia, corneal ulceration, pronounced dysfunction of the motor muscles of the eye, signs of atrophy of the ON.

At the same time, there is a classification by Brovkina, which includes three forms of EOP: edematous exophthalmos, thyrotoxic exophthalmos, and endocrine myopathy. Each of the selected forms eventually passes into the next heavier one.

Treatment of endocrine ophthalmopathy

The method of treatment of EOP is determined by the stage of the process and the presence of concomitant pathologies of the thyroid gland. However, there are also general recommendations, which should be followed without fail:

1. To give up smoking.
2. The use of eye moisturizers (drops, eye gels);
3. Maintain normal thyroid function.

The presence of thyroid dysfunction requires its correction under the supervision of an endocrinologist. In the case of hypothyroidism, thyroxin therapy is used, in case of hyperthyroidism, thyreostatic drugs are prescribed. In the absence of the effectiveness of conservative treatment, surgical removal of part or all of the thyroid gland may be prescribed.

Treatment of EOP by conservative methods. To eliminate signs of inflammation and edema, glucocorticoids or steroid drugs are often prescribed systemically. They are designed to reduce the production of mucopolysaccharides by fibroblast cells, which play an important role in immune responses. For the use of glucocorticoids (methylprednisolone, prednisolone), there are many different schemes that are designed for courses from several weeks to several months. An alternative steroid use may be cyclosporine. Often it is used in combination with them. Severe inflammation or compressive optic neuropathy may require pulse therapy (administration of ultra-high doses in a short time). Evaluation of its effectiveness is carried out after 48 hours. In the absence of such, surgical decompression is advisable.

In the CIS countries, retrobulbar injections of glucocorticoids are still widely used. However, abroad, such a method of treating this pathology has already been abandoned due to its high trauma and the risk of scarring at the injection site. In addition, the effectiveness of glucocorticoids is more related to systemic action, rather than local. These two points of view have long been the subject of discussion, which is why the use of this method of administration is entirely at the discretion of the doctor.

Radiation therapy may be used to treat moderate or severe inflammation, diplopia, and decreased vision. Its action has a damaging effect on lymphocytes and fibroblasts. The expected result appears after a few weeks. Since X-ray radiation can temporarily increase the inflammation process, patients are prescribed steroid drugs in the first weeks of exposure. The best effect of radiation therapy is achieved at the stage of active inflammation, the therapy of which is started up to seven months from the onset of the disease, or in combination with glucocorticoid agents. Its possible risks include the development of cataracts, radiation optic neuropathy, radiation retinopathy. So, one of the studies during irradiation recorded the formation of cataracts in 12% of patients. The use of radiation therapy is not recommended in patients with diabetes mellitus due to the risk of progression of retinopathy.

Surgical treatment of EOP. Approximately 5% of patients with this disease require surgical treatment. Often, EOP surgery is performed in several stages. In the absence of serious complications of the disease, such as compressive optic neuropathy and severe corneal damage, the operation should be postponed until the active process of inflammation has subsided, or carried out at the stage of cicatricial changes. Equally important is the order in which interventions are performed.

Orbital decompression is often performed both as the first stage of surgical treatment of compression optic neuropathy, and in the absence of the effectiveness of conservative therapy. Possible complications of it can be: bleeding, loss of sensitivity of the periorbital zone, diplopia, sinusitis, eyelid displacement, eyeball displacement, blindness.

Strabismus surgery, as a rule, is performed in the period of remission of the EOP, with the stability of the angle of deviation of the eye for at least six months. Treatment is carried out, first of all, to minimize diplopia. Achieving permanent binocular vision is usually difficult, or intervention alone is simply not enough.

In order to reduce mild to moderate exophthalmos, eyelid lengthening surgery is often prescribed. It is an alternative to the introduction of Botox and triamcinolone into the thickness of the upper eyelid subconjunctival. It is also possible to carry out lateral tarsorrhaphy - suturing the lateral edges, which reduces the retraction of the eyelid.

At the final stage of the surgical treatment of EOP, blepharoplasty and punctal plasty are usually performed.

Perspective directions of treatment of EOP. To date, new drugs and methods for the successful treatment of EOP are already being developed. The effectiveness of taking the trace element selenium, which is an antioxidant, the antitumor agent rituximab, inhibitors of tumor necrosis factor - etanercept, infliximab, daclizumab, is being studied.

There are also methods of treating EOP, which are not the main ones, but can be successfully applied in some situations. For example, the introduction of nicotinamide and pentoxifylline, which block the synthesis of mucopolysaccharides in the retroorbital region.

One of the potential mediators of pathological processes in the orbit is insulin-like growth factor-1. Therefore, in the treatment of EOP, they begin to use an analogue of somatostatin - octreotide, to which there are receptors in retrobulbar tissues. Recently, the long-acting analogue of somatostatin, lanreotide, has been undergoing recent clinical trials.

Endocrine ophthalmopathy- a disease of the retrobulbar tissues and muscles of the eyeball of an autoimmune nature, which occurs against the background of a pathology of the thyroid gland and leads to the development of exophthalmos, or bulging eyes, and a complex of eye symptoms. R.J. was the first to describe this disease. Graves in 1835. That is why some authors call the pathology Graves' ophthalmopathy. Until recently, it was believed that endocrine ophthalmopathy is a symptom of an autoimmune thyroid disease - diffuse toxic goiter. Currently, endocrine ophthalmopathy is considered an independent disease.

Both endocrinologists and ophthalmologists are engaged in the study and treatment of patients with this pathology. According to medical statistics, the disease affects about 2% of the total population, and women suffer from it 6-8 times more often than men. Endocrine ophthalmopathy most often manifests itself in two age periods - at 40-45 and 60-65 years. In addition, the literature describes cases of the occurrence of this disease in childhood in girls aged 5-15 years. In 80% of cases, Graves' ophthalmopathy accompanies diseases that cause disturbances in the hormonal function of the thyroid gland, and only in a quarter of cases occurs against the background of euthyroidism - a state of normal functioning of the thyroid gland.

Causes and mechanisms of development of endocrine ophthalmopathy

In 90-95% of cases, endocrine ophthalmopathy develops against the background of diffuse toxic goiter. Moreover, eye damage can be observed both at the height of the underlying disease, and 10-15 years after its treatment, and sometimes long before it.

The basis of endocrine ophthalmopathy is damage to the soft tissues of the orbit, associated with dysfunction of the thyroid gland of varying severity. The reasons triggering the development of endocrine ophthalmopathy have not yet been elucidated. The triggering factors of pathology are retroviral or bacterial infections, exposure to toxins, smoking, radiation, insolation and stress on the body.

The autoimmune nature of the disease is confirmed by the mechanism of its development, in which the patient's immune system perceives the fiber surrounding the eyeball as a carrier of thyroid-stimulating hormone receptors, as a result of which it begins to synthesize antibodies against them (antibodies to the TSH receptor, abbreviated as AT to rTTH). Having penetrated into the fiber of the orbit, antibodies cause immune inflammation, accompanied by infiltration. At the same time, fiber begins to actively produce substances that attract fluid - glycosaminoglycans.

The result of this process is swelling of the cellular tissue of the eye and an increase in the volume of the oculomotor muscles, which create pressure in the bone base of the orbit, which subsequently causes specific symptoms of the disease (primarily exophthalmos, protrusion of the eyeball anteriorly with the onset of a symptom of “bulging eyes”). Over time, the inflammatory process subsides, and the infiltrate degenerates into connective tissue, i.e. a scar is formed, after the formation of which exophthalmos becomes irreversible.

Endocrine ophthalmopathy - classification

There are several types of classifications of endocrine ophthalmopathy. In domestic medicine, the most common classification is according to V.G. Baranov, according to which they distinguish degree of endocrine ophthalmopathy accompanied by certain clinical manifestations.

- 1 degree characterized by slight bulging (up to 16 mm), moderate swelling of the eyelids, without impaired function of the oculomotor muscles and conjunctiva;

- 2 degree accompanied by moderate exophthalmos (up to 18 mm), significant swelling of the upper and lower eyelids, as well as conjunctiva, and periodic double vision;

- 3 degree. It is characterized by pronounced exophthalmos (up to 21 mm), the impossibility of complete closure of the eyelids, erosion and ulcers on the cornea, limited mobility of the eyeball, and signs of optic nerve atrophy.

Also in practice, the classification of endocrine ophthalmopathy by A.F. Brovkina, based on the severity of eye symptoms, and includes three main forms diseases: thyrotoxic exophthalmos, edematous exophthalmos and endocrine myopathy.

Symptoms of endocrine ophthalmopathy

Thyrotoxic exophthalmos manifests clinically as slight true or false protrusion of the eyeballs, retraction of the upper eyelid, due to which there is an expansion of the palpebral fissure, slight trembling of the closed eyelids and insufficient convergence. Morphological changes in retrobulbar tissues are not detected. The range of motion of the periocular muscles is not limited, the fundus of the eye is unchanged.

For edematous exophthalmos bilateral damage to the eyeballs is characteristic, occurring more often at different time intervals, with an interval of up to several months. During this form of endocrine ophthalmopathy, three stages are distinguished.

1. Stage of compensation. The onset of the disease is characterized by a number of specific symptoms, namely, in the morning there is a slight drooping of the upper eyelid, which disappears in the evening. The palpebral fissure closes completely. Over time, partial eyelid drooping transforms into persistent retraction (contraction) due to spasm and prolonged increased muscle tone, which leads to contracture of the Müller muscle and the superior rectus muscle of the eye.

2. Subcompensatory stage. The outer corner of the palpebral fissure and the area along the lower eyelid are affected by white chemosis, intraocular pressure increases and non-inflammatory edema of the periocular tissues develops. The bulging of the eyes grows very quickly, the palpebral fissure ceases to close completely. The vessels of the sclera expand, become convoluted and form a figure resembling a cross in shape. It is this symptom that gives rise to the diagnosis of edematous exophthalmos. When the eyeballs move, there is an increase in intraocular pressure.

3. Decompensatory stage. It is characterized by a sharp increase in symptoms. A large degree of bulging develops, the palpebral fissure does not close at all due to swelling of the eyelids and periocular tissue. The eye is immobilized. There is a development of optic neuropathy, turning into atrophy of the optic nerve. Due to compression of the ciliary nerves, keratopathy and erosive and ulcerative lesions of the cornea develop. If the necessary treatment is not carried out, this stage of edematous exophthalmos ends with fibrosis of the tissues of the orbit and a sharp deterioration in vision due to corneal leukoma or atrophy of the optic nerve.

Endocrine myopathy most often affects both eyes, usually occurs in men against the background of a hypothyroid or euthyroid state. The beginning of the pathological process is manifested by double vision, the intensity of which tends to increase. Then exophthalmos joins. Edema of the periocular tissue in this form of endocrine ophthalmopathy is not observed, but the rectus oculomotor muscles thicken, which leads to a violation of their function and a restriction in the removal of the eyes outward, down and up. The infiltrative stage in this form of endocrine ophthalmopathy is very short-lived, and tissue fibrosis is observed after a few months.

Bulging in Graves' ophthalmopathy must be differentiated from false bulging, which can occur with inflammatory processes in the orbit, tumors, and a significant degree of myopia.

How is endocrine ophthalmopathy diagnosed?

The diagnosis of "endocrine ophthalmopathy" is made on the basis of a complex of instrumental and laboratory research methods carried out by an endocrinologist and an ophthalmologist.

Endocrinological examination involves determining the level of thyroid hormones, detecting antibodies to gland tissues, and ultrasound examination of the thyroid gland. If ultrasound in the structure of the gland reveals nodes more than 1 cm in diameter, a puncture biopsy is indicated.

Ophthalmologist examination consists of visiometry, perimetry, convergence studies. It is obligatory to conduct an examination of the fundus - ophthalmoscopy, determination of the level of intraocular pressure - tonometry. If it is necessary to clarify the diagnosis, MRI, CT, ultrasound of the orbit and biopsy of the oculomotor muscles can be performed.

Treatment of endocrine ophthalmopathy

Options for therapeutic measures aimed at correcting endocrine ophthalmopathy are determined depending on the degree of dysfunction of the thyroid gland, the form of the disease and the reversibility of pathological changes. A prerequisite for successful treatment is the achievement of a euthyroid state (normal levels of hormones T4 St., T3 St., TSH).

The main goals of treatment are moisturizing the conjunctiva, preventing the development of keratopathy, correcting intraocular pressure, suppressing the processes of destruction inside the eyeball and maintaining vision.

Since the process develops against the background of the main autoimmune lesion of the thyroid gland, it is recommended to use the appointment of drugs that suppress the immune response - glucocorticoids, corticosteroids. Pancreatitis, gastric ulcer, thrombophlebitis, tumor processes and mental illness can serve as contraindications to the use of these drugs. In addition, plasmapheresis, hemosorption, cryoapheresis are connected.

Indicators for hospitalization of the patient are such signs as a sharp restriction of the movement of the eyeballs, diplopia, corneal ulcer, rapidly progressive bulging eyes, suspicion of optic neuropathy.

Mandatory correction of thyroid function thyrostatics or hormones. In the absence of the effect of the use of drugs, they resort to thyroidectomy - removal of the thyroid gland, followed by hormone replacement therapy. Currently, it is becoming more and more common to believe that the thyroid gland must be completely removed at the first symptoms of ophthalmopathy, since after the removal of thyroid tissue in the blood, the titer of antibodies to the TSH receptor is significantly reduced. A decrease in antibody titer improves the course of ophthalmopathy and increases the likelihood of a significant regression of its symptoms. The earlier the thyroidectomy is performed, the more pronounced is the improvement in the condition of the eyes.

As symptomatic treatment Endocrine ophthalmopathy is prescribed drugs that normalize metabolic processes in tissues - actovegin, prozerin, vitamins A and E, antibacterial drops, artificial tears, ointments and moisturizing gels. It is also recommended to use physiotherapeutic methods of treatment - electrophoresis with aloe, magnetotherapy on the eye area.

Surgery endocrine ophthalmopathy includes three types of operations - stress relief in the orbit, operations on the muscular apparatus of the eyes and eyelids. The choice in favor of one or another type of surgical intervention depends on the symptoms of the pathological process. Orbit decompression, for example, is indicated for optic neuropathy, severe bulging eyes, ulcerative lesions of the cornea and subluxation of the eyeball. With its help, an increase in the volume of the orbit is achieved due to the removal of one or more walls of the orbit and excision of the periocular tissue.

oculomotor muscles are subjected to operative action with persistent double vision and strabismus, if they are not corrected in a conservative way. Surgery on the eyelids consists of a group of plastic and functional operations, the selection of which is carried out based on the form of the developed disorder (drooping, swelling of the eyelids, retraction, etc.).

Prognosis of endocrine ophthalmopathy

The prognosis of endocrine ophthalmopathy depends on the timeliness of the treatment started. If the disease is diagnosed in the early stages and the correct treatment plan is developed, a prolonged remission of the disease can be achieved and severe irreversible consequences can be prevented. According to statistics, in a third of patients there is a clinical improvement, in two thirds - stabilization of the course of the process. In 5%-10% of cases, further progression of endocrine ophthalmopathy is possible.

After the treatment, ophthalmological control is required after six months, as well as constant monitoring and correction of thyroid function by an endocrinologist. Patients with Graves' ophthalmopathy should be registered at the dispensary.

• Basedow's disease (Graves' disease, diffuse toxic goiter)

  The cause of Graves' disease lies in the malfunctioning of the human immune system, which begins to produce special antibodies - an antithet to the TSH receptor, directed against the patient's own thyroid gland.

• Thyroid hormone analysis

  A blood test for thyroid hormones is one of the most important in the practice of the North-West Endocrinology Center. In the article you will find all the information that you need to read to patients who are going to donate blood for thyroid hormones

• Operations on the thyroid gland

  The North-Western Center of Endocrinology is the leading institution of endocrine surgery in Russia. Currently, the center performs more than 5,000 operations on the thyroid gland, parathyroid (parathyroid) glands, and adrenal glands annually. In terms of the number of operations, the North-West Endocrinology Center steadily ranks first in Russia and is one of the three leading European endocrine surgery clinics

• Endocrinologist's consultation

  Specialists of the North-Western Center of Endocrinology diagnose and treat diseases of the endocrine system. The endocrinologists of the center in their work are based on the recommendations of the European Association of Endocrinologists and the American Association of Clinical Endocrinologists. Modern diagnostic and therapeutic technologies provide optimal treatment results.

• Expert ultrasound of the thyroid gland

  Ultrasound of the thyroid gland is the main method to assess the structure of this organ. Due to its superficial location, the thyroid gland is easily accessible for ultrasound. Modern ultrasound devices allow you to examine all parts of the thyroid gland, with the exception of those located behind the sternum or trachea.

Severe damage to the organs of vision - EOP or endocrine ophthalmopathy - a consequence of autoimmune diseases of the thyroid gland. The clinical picture is a complex of negative signs that adversely affect vision, the condition of the eyelids and eye muscles.

Why is EOP developing? How to recognize the first signs of endocrine ophthalmopathy? How to distinguish an autoimmune disease from infectious lesions of the organs of vision? Can EOP be cured? Answers in the article.

Endocrine ophthalmopathy: what is it

The inflammatory process and edema in the tissues of the retrobulbar region accompanies a complex of ophthalmic symptoms. A characteristic sign is bulging eyes, impaired traction of the upper eyelid, negative changes in the cornea against the background of exophthalmos. Pathology affecting the organs of vision develops against the background of autoimmune lesions of the thyroid gland.

Endocrine ophthalmopathy is one of the complications in Basedow's disease. Bulging is a specific sign of EOP. With bulging eyeballs, the patient should contact an endocrinologist, then visit an ophthalmologist.

Exophthalmos is the first sign of hormonal disorders. With toxic goiter, a quarter of patients develop damage to the organs of vision. Between the development of thyroid pathologies and the appearance of ophthalmopathy, in most cases, 12-18 months pass. In the majority of patients, disturbances in the area of ​​the oculomotor muscles and retrobulbar tissue appear in two eyes. With delayed diagnosis or improper treatment, severe damage to the optic nerve is possible, which can lead to blindness.

In most cases, EOP develops in women: hormonal disorders in this category of patients are more common. Men are less likely to experience endocrine ophthalmopathy, but the symptoms and complications are more severe.

Depending on the severity of the clinical picture, there are several classes of endocrine ophthalmopathy:

• null- there are no negative signs;
• the first- retraction in the area of ​​the upper eyelid, a change in the nature of the look due to the later drooping of the eyelid when closing the eyes;
• second- there is swelling of the eyelids and conjunctiva, sclera;
• third- exophthalmos or bulging is formed;
• fourth- eye muscles are involved in the pathological process: vision is blurry, objects double;
• fifth- lagofalmos develops (with a protruding eyeball it is impossible to completely close the eyelids), on the cornea, due to dryness and constant exposure to atmospheric factors (wind, sun), manifestation zones form, keratopathy appears;
• sixth- the optic nerve is affected, visual acuity rapidly decreases.

Diagnostics

Signs of ophthalmopathy - a reason for a visit to the endocrinologist. It is important to differentiate EOP with eye pathologies of a non-endocrine nature.

For diagnosis, carry out:

• CT of the eye.
• Eye ultrasound.

Additionally, they are prescribed if the patient has not previously contacted a specialized specialist about hormonal disorders in the thyroid gland.

Valid Therapy Options

The nature of therapy depends on the class of EOP. Initially, a complex of drugs is taken, with a low effectiveness of the method, the development of complications, an eye operation is prescribed.

Important! Folk remedies in the treatment of endocrine ophthalmopathy are not used. The disease has an autoimmune nature, herbal decoctions do not have a powerful effect on pathological processes. You can drink a course of herbal remedies to normalize the functioning of the thyroid gland, restore metabolic processes, but only as an additional measure of therapy and for the prevention of endocrine disorders.

Conservative treatment

Tasks of therapy:

• reduce the risk of developing keratopathy;
• moisturize the conjunctiva;
• stop the process of destruction in the tissues of the orbit;
• normalize retrobulbar and intraocular pressure;
• restore vision.

An important point is the stabilization of the hormonal background, the achievement of a euthyroid state. Without the normalization of thyroid function, it is impossible to stop the progression of endocrine ophthalmopathy, to prevent orbital fibrosis and loss of vision.

For the treatment of eye damage, effective names are used:

• Cyclosporine.
• Prednisolone.
• Levothyroxine.
• Sandostatin.
• Methylprednisolone.
• Pentoxifylline.

For the treatment of EOP, a complex of drugs is prescribed:

• thyreostatics;
• thyroid hormones;
• cytokine blockers;
• somatostatin analogues;
• monoclonal antibodies.

If indicated, hemosorption or plasmapheresis is performed to actively remove toxins from the body. Often the doctor prescribes X-ray therapy (16 or 20 Gy is enough for the course).

Antibiotics, glucocorticosteroids, synthetic hormones are used orally and for eye treatment strictly according to the doctor's prescription. It is forbidden to violate the dosing regimen, instructions for use. Improper treatment worsens the prognosis of endocrine ophthalmopathy, provokes loss of vision.

With mild and moderate degree of EOP, the patient undergoes outpatient treatment. Referral to the hospital is required for severe damage to the organs of vision against the background of complications, progressive lagophthalmos and exophthalmos, corneal ulcers, a significant decrease in mobility in the area of ​​the eyeballs and severe drying of the conjunctiva. Hospitalization is mandatory for suspected development of optic neuropathy.

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Surgical intervention

With the low effectiveness of drug therapy, a significant complication of the course of endocrine ophthalmopathy, the doctor prescribes an operation to restore the optimal size of the eyelids, normalize the function of the extraocular muscles. The patient should be observed in a high-level eye center in order to exclude untimely appointment of surgical intervention and adverse reactions after a complex operation.

Indications:

• prolapse and swelling of the lacrimal gland, ptosis, lagophthalmos, retraction - disorders in the eyelids;
• the development of endocrine myopathy with a small retraction of the upper eyelid, a decrease in the functionality of the extraocular muscles;
• expansion in the area of ​​retrobulbar fiber, which provokes serious disorders, a pronounced cosmetic defect against the background of subluxation of the eyeball;
• diplopia. The result of surgery is the restoration of the correct length of important eye muscles.

recovery prognosis

With a timely appeal to an ophthalmologist, it is possible to completely cure the EOP. It is important to carry out competent complex therapy, always under the guidance of an endocrinologist. Often, patients visit an ophthalmologist, who sometimes makes the wrong diagnosis: the result of exposure to a foreign body, blepharitis, conjunctivitis. The best option is to undergo treatment in a special endocrinological center.

Orbital fibrosis is a severe, often irreversible change in the state of the organs of vision. The patient feels pain in the eyeballs, exophthalmos and diplopia develop, and the inflammatory process is activated. Against the background of fibrosis of the orbit, vision deteriorates significantly.

If signs of endocrine ophthalmopathy appear, you can not self-medicate. Therapy under the guidance of an endocrinologist and an ophthalmologist in a specialized medical center is the best option for eliminating pathological manifestations and preventing complications. It is important to know that without normalizing the secretion of thyroid hormones, it is impossible to completely cure the EOP. Lack of therapy or self-medication can lead to blindness, severe damage to all structures of the organs of vision.

You can learn more useful information about the symptoms and treatment of endocrine ophthalmopathy from the following video: