From the Guidelines
Smoking is the most significant modifiable risk factor that worsens eye symptoms in patients with Graves' disease (GD) and orbitopathy, and current smoking has a more detrimental effect than being an ex-smoker. According to the most recent study 1, smoking, diseases resulting in reduced oxygen saturation, and exposure to ionizing radiation increase the risk for and severity of orbitopathy. The study also highlights that radioactive iodine treatment, high anti-thyroid antibody titer, and serum vitamin D deficiency are independent risk factors for developing TED.
Some key points to consider in managing eye symptoms in GD patients include:
- Avoiding smoking and encouraging patients to quit immediately
- Minimizing exposure to environmental irritants such as wind, dust, bright lights, and air conditioning
- Using artificial tears and lubricating ointments to protect the ocular surface
- Maintaining euthyroidism to prevent worsening of eye symptoms
- Considering selenium supplementation (200 mcg daily) to potentially benefit orbitopathy progression
It's essential to note that the risk of TED causing restrictive strabismus increases with age, and a history of prior orbital decompression is associated with an increased risk of strabismus, which worsens with age 1. However, the most critical factor to address is smoking, as it has the most significant impact on worsening eye symptoms in patients with GD and orbitopathy.
From the Research
Factors that Increase Eye Symptoms in Grave's Disease
- High free T3&4 levels may exacerbate eye symptoms, but there is no direct evidence to support this claim in the provided studies.
- Male gender is not specifically mentioned as a factor that increases eye symptoms in Grave's disease in the provided studies.
- Smoking, particularly current smoking, is a significant factor that worsens orbitopathy in patients with Grave's disease 2.
- Ex-smokers have a lower risk of developing orbitopathy compared to current smokers, even with a comparable lifetime tobacco consumption 2. However, ex-smokers may still have a higher risk compared to non-smokers.
Additional Factors
- Low serum selenium levels have been associated with an increased risk of orbitopathy in patients with Grave's disease 3, 4, 5.
- Oxidative stress, which can be increased in smokers, may also play a role in the pathogenesis of Grave's orbitopathy 4.
- Radioactive iodine treatment for Grave's hyperthyroidism may increase the risk of developing orbitopathy, particularly in high-risk individuals who do not receive steroid prophylaxis 6.