Graves' ophthalmopathy and dry eye syndrome

Abstract

Graves ophthalmopathy present different signs and symptoms, in particular ocular surface disease that is the most frequent cause of ocular discomfort. This pathology can lead to increased ocular surface exposure and evaporative dry eye disease, tear-film changes and ocular surface expression of pro-inflammatory cytokines. Patients with ocular surface disease complain of several symptoms from foreign body sensation, blurred vision, dryness, or conjunctival injection, at an estimated prevalence of 65-95%. The most useful assessment is the Ocular Surface Disease Index, which has been shown to be significantly increased in active thyroid-related ophthalmopathy patients. Every increase in clinical activity score of one, double the index values. A careful ocular examination should be performed to assess the severity of the pathology. Superior limbic keratoconjunctivitis, superficial keratopathy and obstructive Meibomian gland disease represent the structural pathological changes; tear break-up time, increase in lacrimal osmolarity and presence of inflammatory cytokines represent the functional changes. Management of dry eye syndrome associated to Graves ’ophthalmopathy can be challenging. Moderate disease may be handled with artificial tears, ointments, and night-time moisture chambers. Topical or oral steroids can be considered to treat the inflammatory component. Surgical intervention consists of early punctual occlusion with temporary punctual plugs. If the patient progresses to sight-threatening ophthalmopathy, surgical intervention may become necessary to reduce exophthalmos and lagophthalmos. Standardized treatment guidelines are not available, and the management depends on patient’s disease activity and severity. A stepwise approach must be applied, ranging from conservative management to surgical intervention combined with topical or systemic therapy.