Graves’ Disease or Basedow-Graves Disease: Causes, Symptoms, Ophthalmopathy, Dermopathy

Graves’ disease is a medical condition occurring as a result of dysfunction of the immune system. This disease is characterized by excessive production of the thyroid hormones, i.e. it results in hyperthyroidism. Graves’ Disease or Basedow-Graves Disease is the most common cause of hyperthyroidism; although it can develop from other causes also. As there are different body systems affected by thyroid hormones, signs and symptoms produced from Graves’ disease are varied and have a considerable influence on a person’s general health.

Graves’ disease is not a life-threatening or a serious condition. Graves’ Disease or Basedow-Graves Disease commonly affects women under the age 40; although people from any gender or age groups can suffer from it.

Treatment is done by trying to decrease the production of thyroid hormones and providing the patient relief from symptoms.

Graves’ Disease or Basedow-Graves Disease occurs due to problem with our immune system. Normally our immune system produces antibodies in response to invasion by foreign body, virus or bacterium. What happens in Graves’ disease is, our body starts to produce an antibody for a specific protein present on the surface of the thyroid cells resulting in overproduction of the thyroid hormone. The cause of this is not clear.

Graves’ Disease or Basedow-Graves Disease affects many body functions such as: Metabolism, heart and nervous system function, temperature of the body, strength of the muscle, menstrual cycle and affects the overall quality of life of a patient.

• Having a family history of Graves’ disease increases the risk for developing it.
• Women are more susceptible to develop Graves’ disease than men.
• Individuals younger than 40 years are more likely to develop Graves’ disease.
• Individuals with other immune system disorders are at an increased risk for developing Graves’ disease.
• Any type of stress, whether physical or emotional, can trigger the development of Graves’ disease.
• Being pregnant and recent childbirth increases the risk of developing Graves’ disease.
• Smoking affects the immune system and puts the smokers at an increased risk for Graves’ disease.

• Irritability and anxiety.
• Insomnia or difficulty in sleeping.
• Tiredness.
• A very slight tremor of fingers or hands.
• Irregular or rapid heartbeat.
• Heat sensitivity.
• Diarrhea.
• Warm and moist skin or excessive perspiration.
• Goiter (thyroid gland enlargement).
• Unintentional weight loss.
• Decreased libido or erectile dysfunction.
• Alteration in the menstrual cycles.
• Graves’ ophthalmopathy (bulging eyes) and Graves’ dermopathy.

Around 50% of the patients who are suffering from Graves’ disease may also have Graves’ ophthalmopathy; a condition where there is inflammation of the muscles and the surrounding tissues of the eyes.

• Bulging eyes.
• Excessive watering.
• Feeling of sandy or gritty sensation in the eyes.
• Irritation and dryness of the eyes.
• Pain in the eyes.
• Eyelids become puffy.
• Feeling of the pressured in the eyes.
• Redness or inflammation of the eyes.
• Double vision.
• Blurred or decreased vision.
• Photophobia or sensitivity to light.
• Fixed stare due to limited eye movements.
• Corneal ulcers.

This is a rare manifestation of Graves’ disease characterized by thickening and reddening of the skin, especially on the shins or on top of the feet.

• Physical exam where the doctor will examine the patient’s eyes for irritation, inflammation or protrusion and to look for enlargement of the thyroid gland. Patient is also checked for irregularities in the pulse, blood pressure and for any signs of tremor.
• Blood tests to assess the levels of TSH or thyroid-stimulating hormone and pituitary hormone.
• Radioactive iodine uptake is done to determine the speed with which the thyroid gland takes up the iodine. This is done using a specialized scanning camera.
• Imaging tests such as CT scan MRI scan for further assessment.

The aim of the treatment is to decrease the production of thyroid hormones and to impede the effect of the excessive hormones on the patient’s body. Treatment includes:

Radioactive iodine (radioiodine) is given orally and this gradually kills the overactive thyroid cells resulting in shrinkage of the thyroid gland and decrease in the symptoms. The benefits can be seen over a period of many weeks to months.

The downside of radioiodine therapy is that it could increase the risk of Graves’ ophthalmopathy or may worsen existing symptoms of Graves’ ophthalmopathy; although this is temporary and mild, still this therapy is not recommended if the patient is already suffering from eye problems.

Other side effects of this therapy are: Neck tenderness, temporary elevation of the thyroid hormones and temporary decrease in testosterone (males). Radioiodine therapy is contraindicated in pregnant or nursing women. The leftover radioiodine which is not taken up by the thyroid gland is excreted via urine and saliva.

As this treatment results in decrease of the thyroid activity, patients may require additional treatment so that the body can meet the requirement of normal thyroid hormones.

These medications, such as propylthiouracil and methimazole, affect the use of iodine by the thyroid in order to produce hormones. There may be a relapse of hyperthyroidism if these two drugs are used alone. It is better to take these medicines for more than a year for far-fetching results. Anti-thyroid medicines can also be used after or before the radioiodine therapy as an additional treatment.

Side effects of these drugs are: Joint pain, rash, liver failure, decrease in WBCs. These medications, especially methimazole, are contraindicated in pregnant women. Propylthiouracil is relatively safer to use in pregnant women.

Beta-Blockers do not stop the thyroid hormone production; what they do is block the effect these hormones have on the body. Side effects include: Irregular/rapid heartbeats, tremors, irritability/ anxiety, heat sensitivity, diarrhea, sweating, muscle weakness and diarrhea.

Some of the beta blockers are: Propranolol, atenolol, metoprolol and nadolol. Beta blockers are not recommended in patients suffering from asthma and diabetes. It’s important to stop this medication under your doctor’s guidance, as stopping this medicine abruptly results in serious heart problems.

If therapies don’t benefit the patient or for some reason the patient is unable to tolerate them, then surgery is done for removing the thyroid gland and this surgery is known as thyroidectomy. Post surgery, patients need additional treatment to supply their body with the normal amount of thyroid hormones. Risks of this surgery are: Possible damage to the vocal cords and parathyroid glands.

If the symptoms of Graves’ ophthalmopathy are mild, then they can be managed by using OTC artificial tears in the day and lubricating gels at night. For severe symptoms, the following treatment is done:

• Corticosteroids, such as prednisone, help in reducing the swelling behind the eyeballs. Side effects are: Weight gain, fluid retention, increased blood sugars, mood swings and hypertension.
• Orbital decompression surgery comprises of removing the bone between the orbit or eye socket and the sinuses resulting in increased space, so that the eyes can return to their normal position. This treatment is commonly done if there is a risk of vision loss due to pressure on the optic nerve.
• Eye muscle surgery is done for inflammation of the eye muscles, as a result of Graves’ disease, causing shortening of the muscles, so that the eyes are not aligned properly. In this surgery, the muscle attached to the eyeball is cut and reattached further back. Patient may need more than one surgery.
• For double vision resulting as a side effect of surgery for Graves’ disease or from Graves’ disease itself, prisms in the glasses could correct the double vision.
• Orbital Radiotherapy: This used to be a common treatment for Graves’ ophthalmopathy. It comprises of targeting x-rays for many days to destroy a part of the tissue present behind the eyes.

• It is very important to follow a healthy diet and an exercise regime. Bringing these changes into your life help in improving some of the symptoms. It will help you with the weight gain which occurs after the hyperthyroidism is corrected. Weight-bearing exercises also help with the brittle bones occurring as a result of Graves’ disease.
• Avoid stress, as stress can worsen or trigger Graves’ disease. Meditate, take a long walk, listen to soothing music, read a nice book or take a warm bath; anything to keep you relaxed.
• Discuss with your doctor to come up with a good diet and exercise plan to follow daily.

• Application of cool compresses to the eyes helps in soothing the eyes.
• Protrusion of the eyes makes them more vulnerable to the UV rays and makes them photosensitive. Always wear wraparound sunglasses to avoid these problems when stepping outside.
• Lubricating eye drops helps in relieving the dry and gritty sensation of the eyes.
• Try to keep your head elevated than the rest of your body when sleeping, so as to reduce fluid retention in the head thus decreasing the pressure on the eyes.

For Graves’ Dermopathy, OTC ointments or creams which contain hydrocortisone help in relieving the reddening and swelling of the skin. Compression wraps on the legs also help with the symptoms.