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Graves' Disease (Exophthalmic Goiter)


Disease: Graves' Disease (Exophthalmic Goiter) Graves' Disease (Exophthalmic Goiter)
Category: Endocrine and metabolic diseases
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Disease Definition:

The most common form of hyperthyroidism is Graves' disease, which occurs when a person's immune system mistakenly attacks the thyroid gland causing it to overproduce the thyroxine hormone. The body's metabolic rate could be greatly increased by this higher thyroxine level, affecting the person in numerous ways, from their physical appearance to their moods.


Only in some extremely rare cases is Graves' disease life-threatening. This disease is more common in women and usually starts after the age of 20, despite the fact that it could develop at any age and in women as well as men.


Treatment for Graves' disease could ease symptoms and decrease the production of thyroxine. However, there's no way of stopping the immune system from attacking the thyroid gland.

Work Group:

Prepared by: Scientific Section

Symptoms, Causes


Some of the signs and symptoms of Graves' disease may include:


  • Difficulty sleeping
  • Fatigue
  • Brittle hair
  • Irritability
  • Sensitivity to heat
  • Change in menstrual cycles
  • Increased perspiration
  • A rapid or irregular heartbeat
  • Frequent bowel movements
  • Anxiety
  • Goiter, which is the enlargement of the thyroid gland.
  • A fine tremor of the hands or fingers
  • In spite of normal food intake, weight loss



Graves' ophthalmopathy could cause some mild signs and symptoms in the eyes. In this type of the disease, the eyes bulge past their protective orbit (exophthalmos), which occurs as the tissues and muscles behind the eyes swell and cause the eyeballs to move forward. The eyes could become dry when they are pushed so far forward. Graves' ophthalmopathy is five times more likely to develop in cigarette smokers with Graves' disease, because the absorption of anti-thyroid medication that is used to treat Graves' disease is inhibited by smoking.


Some of these mild signs and symptoms could be caused by Graves' ophthalmopathy:


  • Inflamed or reddened eyes
  • Sensitivity to light
  • Widening of the space between the eyelids
  • Either in one or both of the eyes, excess tearing and sensation of grit or sand
  • Swelling of the lids and tissues around the eyes


These are some of the more serious signs and symptoms that could be caused by Graves' ophthalmopathy in some cases:


  • Double vision
  • Blurred or reduced vision
  • Ulcers on the cornea
  • Limited eye movements



Reddening and swelling of the skin, usually on the shins and on the top of the feet is an uncommon sign of Graves' disease called Graves' dermopathy.


In case a person has signs and symptoms that suggest Graves' disease they should see a doctor, especially if they experience:


  • Anxiety
  • Tremor
  • An enlarged thyroid
  • Weight loss
  • Intolerance to heat
  • Protruding eyes


If a person is experiencing rapid or irregular heartbeat or other heart-related signs and symptoms, they should seek emergency care.


The exact cause of Graves' disease is still not known. Typically, in order to help eliminate viruses, bacteria and foreign substances (antigens) that invade the body, the immune system uses naturally occurring proteins called antibodies and white blood cells called lymphocytes.


As mentioned before, the immune system mistakenly attacks the thyroid gland in Graves' disease. However, instead of destroying the gland, an antibody called TRAb (thyrotropin receptor antibody) stimulates the thyroid to make excessive amounts of thyroid hormone.


The thyroid is part of the endocrine system, which includes a collection of glands and tissues that produce hormones. Many of the body's activities, from digestion to metabolism to reproduction are coordinated by these chemical messengers. Many body systems are affected by thyroxine, the hormone that is produced by the thyroid, which is also involved in controlling a person's metabolic rate.



A number of complications could be caused whenever a person's body produces too much thyroid hormone due to Graves' disease or any other cause. These complications may include:


Brittle bones:

Weak and brittle bones (osteoporosis) could be due to untreated hyperthyroidism. The strength of a person's bones depends in part on the amount of calcium and other minerals that they contain. Too much thyroid hormone will interfere with the body's ability to incorporate calcium into the bones.


Heart problems:

The heart is involved in some of the most serious complications of hyperthyroidism, such as a heart rhythm disorder known as atrial fibrillation, a rapid heart rate and congestive heart failure, a condition in which the heart cannot circulate enough blood in order to meet the body's needs. With appropriate treatment, these complications are usually reversible.


Thyrotoxic crisis:

A person will be at risk of developing thyrotoxic crisis in case they are suffering from hyperthyroidism. In this crisis the person will experience a sudden intensification of their signs and symptoms, which will cause delirium, a rapid pulse and a fever. Though rare, but if it occurs, the person should seek immediate medical care.


The immune system cannot be stopped from producing the antibodies that cause Graves' disease. Treatments that decrease the production of thyroxine or even block its action can be used in controlling the signs and symptoms of Graves' disease. Some of these treatments include:


Anti-thyroid medications:

The thyroid will be prevented from producing excessive amounts of hormones by these prescription medications, which include methimazole and propylthiouracil. Usually, treatments that involve anti-thyroid medications last at least a year. In some cases, one to two years of treatment with anti-thyroid medications end up causing a long-term remission of the disease, but relapse is quite common. In order to help control signs and symptoms, these drugs are usually used with surgery or radioactive iodine treatment. Both of these drugs could cause serious liver damage, in some cases leading to death. However, propylthiouracil should only be used when the patient cannot tolerate methimazole, because propylthiouracil has been noted to cause far more damage.


Beta blockers:

Rapid heart rate, nervousness and tremors, along with other signs and symptoms of hyperthyroidism are relieved by these medications, which include metoprolol, atenolol, nadolol and propranolol. Because the body will still produce too much thyroxine, these medications are not a cure for Graves' disease; however, some of the action of the thyroid hormone will be blocked by beta blockers. In most cases, beta blockers are used in conjunction with other types of treatment.


Radioactive iodine treatment:

The body needs iodine and usually uses whatever form of iodine is available in the blood to make thyroid hormone. In case someone takes radioactive iodine, the iodine will collect in the thyroid gland, and in the course of time, the overactive thyroid cells will be destroyed by radioactivity. This process will cause the thyroid gland to shrink, and over several weeks to several months, the person's problems will lessen gradually. A person will most likely need thyroxine treatment to supply their body with normal amounts of thyroid hormones, because radioactive iodine treatment causes thyroid activity to decline. Thyroxine treatment doesn't require a hospital stay.


A person's risks of new or worsened symptoms of Graves' ophthalmopathy are increased with radioactive iodine treatment. This side effect is often mild and temporary, however, if the person already has moderate to severe eye problems, they may not be recommended radioactive iodine therapy. After the person undergoes radioactive iodine treatment, any iodine that is not taken up into the thyroid gland will be excreted in their saliva and urine.



Thyroidectomy, which is surgery to remove the thyroid gland, may be an option in case a person cannot tolerate any anti-thyroid drug and doesn't want to have radioactive iodine therapy. After the surgery, in order to supply the body with normal amounts of thyroid hormones, they will probably need thyroxine treatment.
Potential damage to the vocal cords and parathyroid glands, which are the tiny glands located adjacent to the thyroid gland, are some of the risks of this surgery. The level of calcium in the blood is controlled by a hormone that is produced by the parathyroid glands. If the surgeon is experienced in thyroid surgery, the patient's chances of complications will be rare.



In case Graves' disease has affected the patient's eyes (Graves' ophthalmopathy), their mild symptoms could be managed by using artificial tears liberally during the day, in addition to lubricating gels at night. However, a person may be recommended these treatments in case their symptoms are severe:



Swelling behind the eyeballs could be diminished by treatment with prescription corticosteroids, such as prednisone.


Orbital decompression surgery:

The bone between the eye socket (orbit) and the sinuses (the air spaces next to the orbit) will be removed in this surgery, so that the eyes are given room in order to move back to their original position. Lip numbness and double vision are some of the possible complications.


Eye muscle surgery:

A person's eye muscles could be affected by the inflammation that is caused by Graves' disease making these muscles too short to allow the eyes to align properly. In this surgery, the muscle will be cut where it attaches to the eyeball, and then it will be reattached farther back. In some cases, the patient may need more than one operation.



Either because of Graves' disease or as a side effect of surgery for Graves' disease, a person may have double vision. Prisms in the glasses could correct double vision; however, they don't work for everyone.


Orbital radiotherapy:

Once a common treatment for Graves' ophthalmopathy, orbital radiotherapy uses targeted X-rays over the course of several days in order to destroy some of the tissue behind the eyes. However, it has been suggested that this treatment doesn't provide any benefit for people with mild to moderately severe Graves' ophthalmopathy. In case someone's eye problems are worsening and prescription corticosteroids alone are not well tolerated or effective, he/she may be recommended orbital radiotherapy.


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Consultants Corner

Dr . Dirar Abboud

Dr . Dirar Abboud Hepatologist – Gastroenterologist

Dr. Tahsin Martini

Dr. Tahsin Martini Degree status: M.D. in Ophthalmology

Dr. Talal Sabouni


Yaser Habrawi , F.R.C.S.Ed

Yaser Habrawi , F.R.C.S.Ed Consultant Ophthalmologist

Dr. Samer Al-Jneidy

Dr. Samer Al-Jneidy Pediatrician

Samir Moussa M.D.

Samir Moussa M.D. ENT Specialist

Dr. Faisal Dibsi

Dr. Faisal Dibsi Specialist of Otolaryngology - Head and Neck Surgery

Dr. Hani Najjar

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