31.20.34 Ocular Manifestations in Thyroid Disorders in Karachi

Original Article

 

Ocular Manifestations in Thyroid Disorders

Ocular Manifestations in Thyroid Disorders in Karachi

Abdul Hameed Siddique1, S. Ali Haider2, Akhtar Ahmed Baloch3, Jawaid Sami4, Munir Ahmed Shaikh5 and Sahira Wasim1

ABSTRACT

Objective: To analyze the ocular findings in thyroid disorders presented in Karachi.

Study Design: A Cross-sectional study

Place and Duration of Study: This study was conducted at the outpatients departments of two tertiary care hospitals of Karachi, Liaquat National Hospital and Dow University of Health Sciences Ojha Campus, Karachi in the department of Endocrinology and Ophthalmology from June, 2018 to June, 2019.

Materials and Methods: Inclusion criteria of thyroid disorder patients were; age between 12-60 years, known hypothyroidism or hyperthyroidism, finding of thyroid abnormalities and visible goiter or exophthalmos. The exclusion criteria were, known diabetic or hypertensive, on iodine containing drugs, pulsatile exophthalmos, poly glandular autoimmune diseases and lens/corneal/retinal abnormalities. One hundred and eleven patients were selected according to the inclusion criteria. After consent recent detailed history, clinical examination and ophthalmic examinations were done. Required laboratory and radiological investigations were done and analyzed. The data were entered in SPSS version 20 for descriptive and other relevant statistical analysis. Each patient was examined with slit lamp for anterior segment, snellen chart for measurement of visual acuity, ophthalmoscope for fundoscopy, Goldmann Applanation Tonometer for intraocular pressure measurement, Torch for examination of pupil and extraocular movements and Hertel exophthalmometer to measure amount of exophthalmos. CT and (Hertel) MRI in selected cases were done.

Results: The mean age of involvement was 39+/- 15 years and there was female preponderance 2.6:1. Out of 111 patients 70% were hyperthyroid and 30% were fixed with the diagnosis of hypothyroidism. Almost 20% had bilateral proptosis while unilateral exophthalmos was 5.5%. Goiter was visible among 28%. Around 20% had family history of thyroid disorders and habitual usage of iodized salt was 17%. Addiction to smoking was 26%. The main ocular sign in hyperthyroidism was ocular pressure and increased myopia and while xerosis of eyes and loss of hairs in eyebrows were main ocular presentation among hypothyroidism. The most elicited sign in hyperthyroidism was lid lagging and eye protrusion while congested eye lids, dry eyes and weak ocular movements were main signs among hypothyroidism. Marcus Gunn pupil and papilledema were present in 2 patients. Optic neuropathy was present in one patient. The latter signs were red flag signs of oculopathies in hyperthyroidism.

Conclusion: Eyes are good representative of thyroid disorders if examined according to the standard protocol. Hyperthyroidism has sine qua non ocular markers while in hypothyroidism the slow basal metabolic rate represents in eyes as xerosis and loss of eyebrows.

Key Words: Ocular manifestations, thyroid eye diseases

Citation of article: Siddique AH, Haider SA, Baloch AA, Sami J, Shaikh MA, Wasim S. Ocular Manifestations in Thyroid Disorders in Karachi Med Forum 2020;31(10):143-147.

 

 

INTRODUCTION

 

1. Department of Ophthalmology, Liaquat National Hospital & Medical College, Karachi.

2. Department of Medicine, Jinnah Sindh Medical University, Karachi.

3. Department of Medicine / Endocrinology4, DUHS, Karachi

5. Department of Medicine, Baqai Institute of Health Sciences, BMU, Karachi.

 

 

Correspondence: Dr. S. Ali Haider, Visiting Professor of Medicine, Jinnah Sindh Medical University, Karachi.

Contact No: 0302-8252299

Email: alihaider1950@gmail.com

 

 

Received:    February, 2020

Accepted:    July, 2020

Printed:        October, 2020

 

 

Thyroid disorders are one of the diseases which have specific peripheral stigmata or target organ involvement.1 Thyroid dysfunction has specific changes in whole eye including adjacent structures that is thyroid orbitopathy.2 It is said that if these ocular signs are present in euthyroid status, the patients in future ultimately develop the clinical features of thyrotoxicosis with biochemical evidence.3 This is an interesting fact that hypo and hyper function of thyroid gland, both can involve the specific changes in eye4. Incidence of thyroid eye disease (TED) in hyperthyroidism is 77% and less frequently in euthyroid 20% and 3% among hypothyroidism in most of the studies conducted around the world.5 In Pakistan the ocular manifestations associated with thyroid disorders varies between 27%-46% in different locations of the country.6 TED is one of the mysterious disease in which pathogenesis is arguable since many decades. Exact pathology is yet not known however different theories are suggested7. Infact the pathogenesis is multifactorial.8 The most important pathogenesis effect detected is increased TSH, T3, T4 and increment of receptors in the orbit.9The other important role is after the initiation of inflammation intraorbitally the influx of neutrophils followed by lymphocytes and fibroblasts.10Other factor postulated is release of long acting thyroid stimulating hormone and exophthalmos producing substance.11 Another view widely accepted is the production of antibodies against different constituents of orbit especially intra ocular muscles.12 Histopathology in cadavers had shown excessive deposition of muccopolysaccharides inside the orbit.12

MATERIALS AND METHODS

This is an observational cross-sectional study conducted at Liaquat National Hospital and Dow University of Health Sciences Ojha Campus, Karachi in the department of Endocrinology and Ophthalmology from June 30th, 2018 to June 30th, 2019. The study was approved by Institutional and Ethical Review Committees of both institutions. Verbal consent was taken from each patient included and recorded. Inclusion criteria were, (a) known patient of thyroid disorders for at least 6 months, (b) known or detected unilateral or bilateral exophthalmos, (c) goiter clinically visible or palpable, (d) biochemical evidence of thyroid hyper or hypo function, (e) age between 12-60 years to exclude genetic disorders and degenerative impact on eyes.Exclusion criteria were, (a) known case of diabetes and hypertension, (b) those who took iodinated compounds for more than 6 months, (c) polyglandular autoimmune diseases, (d) those who had bilateral cataracts and retinal/corneal abnormalities, (d) pulsatile exophthalmos. The patients were selected from the Outpatient Departments and indoors of the hospitals fulfilling the inclusion criteria. The detailed history and clinical examination were done by the consultants and full ophthalmological reviews were done by the ophthalmologists for ocular findings. The investigations were also analyzed by the consultants including thyroid function tests, thyroid scan, and MRIs of the orbits where indicated. Autoimmune profile was also obtained in the indicated patients. All the informations were recorded in patients profile and then entered in SPSS, version 20 for data analysis. Chi square statistical test is applied where indicated and p value of <0.05 was taken as statistically significant.

RESULTS

One hundred and eleven patients were enrolled in the study as per inclusion criteria. Their ages range between 12-60 years and the mean age was 39±15 years. The proportion of females was 78/111 that becomes 70.2% and females to males ratio was 2.3:1. Overall as per thyroid function tests, 78/111 or 70.2% had hyperthyroidism and 33/111(29.7%) had hypothyroidism. Twenty two patients, 22/111 or 20% had bilateral proptosis while 6/111(5.4%) had unilateral exophthalmos. Thirty one patients 31/111 or 27.9% had clinical goiter and 23/111 that is 20.7% had positive family history of thyroid disorders. Forty one patients 41/111 belonged to rural areas of Sindh. Habitual use of iodized salt were present in 19/111 patients that is 17.1% and all belonged to urban areas. Twenty nine patients or 26.1% (24 males and 5 females) were addicted to cigarette smoking or huqqa. Sixty eight patients that is 68/111 or 61.2% were already on anti-thyroid drugs/thyroxine. Clinical presentation in hyperthyroidism and hypothyroid patients are shown in table 1 and the specific ocular changes /signs of comparison between hypothyroidism and hyperthyroidism is depicted in table No 2.

 

 

 

 

 

Table no.1 Occular clinical presentations of hyperthyroidism and hypothyroidism

S. No

Symptoms / Hyperthyroidism (78) Patients

Symptoms / hypothyroidism (33) patients

 

Clinical presentations              

 

No of patients

No of patients

Total Count

1

Dry eyes

63

31

94(85%)

2

Puffiness of eyelids

41

24

65(59%)

3

Gazing eyes

79

2

           81(73%)

4

Reduction in visual acuity

54

7

           61(55%)

5

Vision loss

3

0

           3(2.7%)

6

Disturbance in color vision

2

0

          2(1.8%)

7

Proptosis

3

0

          3(2.7%)

8

Ocular pressure (pain)

78

0

         78(70.27%)

 

 

 

 

 

Table No.2: Comparison of ocular signs in hyper/hypothyroidism

S.No

Signs in Thyroid Disorders

Variants of Hyperthyroidism (78/111)

Variants of Hypothyroidism (33/111)

Grave's Diseases

Thyrotoxicosis

Toxic Nodular rGoitre

CA- Thyroid

Auto immuneThyroiditis

Drug induced

Secondary

Auto Immuno Thyroiditis

Nutritional

Subclinical (MTF)

Secondary

1

Number of Patients

38

24

7

1

2

3

2

17

7

8

1

2

Visual Acquity disturbed

24

7

2

0

2

2

2

10

5

7

1

3

Color vision

5

0

0

0

0

0

0

0

0

0

0

4

Disturbance in field of vision

15

2

3

0

0

0

0

0

0

0

1

5

Conjunctiva red

33

17

3

1

1

1

1

3

1

1

0

6

cornea normal

33

17

3

1

2

3

2

17

7

8

1

7

Eye lashes/ loss of hair

0

0

1

0

0

0

0

8

2

0

1

8

RAPD

2

0

0

0

0

0

0

0

0

0

1

9

Vongraffe sign

38

21

5

1

2

2

0

0

0

0

1

10

Proptosis unilateral

5

1

0

0

0

0

0

0

0

0

0

11

Proptosis bilateral

18

2

0

0

0

0

1

0

0

0

1

12

Restricted eye movements

11

3

1

0

0

0

0

0

0

0

1

13

Optic neruropathy

4

0

0

0

0

0

0

0

0

0

0

14

Pappiloedema

2

0

0

0

0

0

0

0

0

0

0

15

Xerosis of eyes

0

0

0

0

0

0

0

24

3

1

1

 

 

ABBV…RAPD…Relative afferent pupillary defect. MTF..mild thyroid failure.

 

 

 

DISCUSSION

It is known from ancient times that swelling of eyes is related to thyroid glands.15 Inspite of the disputed pathogenesis of ocular manifestations related to thyroid disorders specific eye changes are seen in both hyper and hypothyroidism.16 Overall, females are more involved than males in this research article supported by many researchers.17 The female preponderance is most probably due to the sensitivity to estrogen, pregnancy and lactation.18 In this study the  prevalence of hyperthyroidism is more than hypothyroidism which is against the study done by Knuden and co-workers.19 In year 2000 in Denmark and surrounding temperate zones were hypothyroidism more seen. Probably in our areas sufficient iodine in water and food cause Weil-Cheikoff effect which cause enhancement for hyperactivity of gland, twenty five percent in our study showed exophthalmos among them almost 5% was unilateral. As compared to American and European countries where proptosis is more than 42-45% among overall hyperthyroid patients but this figure is lower because of genetic, racial and environmental factors.20 In our study the family history was present in 20.7% while study done by Medgalchi and his co-workers found the higher association that is > 60.5% in the areas near Turkey border.21 This difference is probably due to higher rate of consanguineous marriages and iodine content in water and soil. Indigenous usage of iodine salts in diet and food, very low/high in iodine content has positive and negative influence on thyroid eye diseases. In our study the habitual use of iodized salt was 17.1% supporting the study done by Rati and Uberti in 2004.22Smoking has linear relationship found in this study supported by work done by Kim and co-researchers in 2019.23 The major ocular symptoms in hyperthyroid in this study was xerosis of eyes with puffiness and gazing stance, increase in myopic error and ocular pressure while in hypothyroidism, dryness of eyes with grittiness, puffy eyelids and reduced visual acuity. These observations are supported by Perroz and coworkers in 200923.

The main  etiology of hyperthyroidism in this study was Graves’ disease, thyrotoxicosis, toxic multinodular goiter and toxic solitary nodular goiters among the majority of cases while the cause of hypothyroidism in this study was Hashimoto’s thyroiditis (autoimmune) and nutritional and sub-clinical hypothyroidism. There was one case of secondary hypothyroidism and two were detected as secondary hyperthyroidism. These facts are supported by many studies done in the last 4 decades especially elaborated in a study done by Kurian and colleagues in 2008.24 The major signs in ophthalmology of hyperthyroidism were reduction of visual acuity plus increased myopia, congested conjunctiva, fullness of eyes, infrequent blinking, limited upward gaze, vongraffe sign, relative afferent pupillary defect (RAPD) and papilledema while 4 cases of optic neuropathy were detected. These signs are supported by the study done by Satli and Gunduz in 201725. The major ocular signs in hypothyroidism in this study were xerosis of eyes, loss of hairs of eyelashes and lateral one third of eyebrows and only one patient who had primary hyperthyroidism demonstrated proptosis. These observations are supported by the study done by Mahto in 197226.

CONCLUSION

Thyroid disorders either manifest as hyper or hypothyroidism has specific ocular changes. In majority of cases in hyperthyroidism, decrease in visual acuity, conjunctival injection, propotosis, lid lagging, gazing stance and weakness of extra ocular muscles are major manifestations. On the other hand, in hypothyroidism, xerosis of eyes and loss of hair of eye lashes and brows are common presentations. Blindness can occur due to optic neuropathy in severe untreated cases. The impact of genetics, smoking and indigenous use of iodized salts on thyroid functions and associated ocular changes are also highlighted.

Author’s Contribution:

Concept & Design of Study:

Abdul Hameed Siddique

Drafting:

S. Ali Haider, Akhtar Ahmed Baloch

Data Analysis:

Jawaid Sami, Munir Ahmed Shaikh, Sahira Wasim

Revisiting Critically:

Abdul Hameed Siddique, S. Ali Haider

Final Approval of version:

Abdul Hameed Siddique

Conflict of Interest: The study has no conflict of interest to declare by any author.

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