Endocrine ophthalmopathy – the organospetsifichesky progressing defeat of soft fabrics of an orbit and an eye developing against the background of autoimmune pathology of a thyroid gland. The course of an endocrine ophthalmopathy is characterized ekzoftalmy, a diplopiya, puffiness and an inflammation of tissues of eye, restriction of mobility of eyeballs, changes of a cornea, DZN, intraocular hypertensia. Diagnosis of an endocrine ophthalmopathy demands carrying out ophthalmologic inspection (an ekzoftalmometriya, biomicroscopy, orbit KT); researches of a condition of immune system (determination of the Ig level, At to TG, At to TPO, anti-nuclear antibodies, etc.), endocrinological inspection (T4 St., T3 St., ultrasonography of a thyroid gland, a punktsionny biopsy). Treatment of an endocrine ophthalmopathy is directed to achievement of an eutireoidny state; can include medicamentous therapy or removal of a thyroid gland.
Endocrine ophthalmopathy (tireoidny ophthalmopathy, Greyvs's ophthalmopathy, autoimmune ophthalmopathy) – the autoimmune process proceeding with specific defeat of retrobulbarny fabrics and which is followed ekzoftalmy and oftalmoplegiy various degree of expressiveness. For the first time the disease was in detail described by K. Greyvs in 1776.
Endocrine ophthalmopathy - the problem which is of clinical interest to endocrinology and ophthalmology. An endocrine ophthalmopathy suffers from about 2% of all population, at the same time among women the disease develops in 5-8 times more often than among men. Age dynamics is characterized by two peaks of a demonstration of an ophthalmopathy of Greyvs – in 40-45 years and 60-65 years. The endocrine ophthalmopathy can also develop at children's age, a thicket at girls of the first and second decade of life.
Reasons of an endocrine ophthalmopathy
The endocrine ophthalmopathy arises against the background of primary autoimmune processes in a thyroid gland. The eye symptomatology can appear along with clinic of damage of a thyroid gland, precede it or develop in the remote terms (on average in 3-8 years). The endocrine ophthalmopathy can accompany a thyrotoxicosis (60-90%), a hypothyroidism (0,8-15%), an autoimmune tireoidit (3,3%), the eutireoidny status (5,8-25%).
The factors initiating an endocrine ophthalmopathy are still finally not found out. As triggers respiratory infections, small doses of radiation, insolation, smoking, salts of heavy metals, the stress, autoimmune diseases (diabetes and so forth) causing the specific immune answer can act. The association of an endocrine ophthalmopathy with some anti-genes of HLA system is noted: HLA-DR3, HLA-DR4, HLA-B8. Soft forms of an endocrine ophthalmopathy meet among persons of young age more often, severe forms of a disease are characteristic of elderly people.
It is supposed that owing to a spontaneous mutation T-lymphocytes begin to interact with receptors of membranes of cells of eye muscles and cause in them specific changes. Autoimmune reaction of T-lymphocytes and cages targets is followed by release of tsitokin (Interlaken, a factor of a necrosis of tumors, γ-interferon, the transforming factor of growth of b, a factor of growth of platelets, an insulinopodobny factor of growth 1) which induce proliferation of fibroblast, formation of collagen and development of glikozaminoglikan. The last, in turn, promote water binding, development of hypostasis and increase in volume of retrobulbarny cellulose. Hypostasis and infiltration of fabrics of an orbit are replaced over time by a fibrozirovaniye therefore becomes irreversible.
Classification of an endocrine ophthalmopathy
In development of an endocrine ophthalmopathy allocate a phase of an inflammatory ekssudation, a phase of infiltration which is replaced by a phase of proliferation and fibrosis. Taking into account expressiveness of eye symptomatology allocate three forms of an endocrine ophthalmopathy: tireotoksicheskiya , edematous and endocrine myopathy. Tireotoksichesky is characterized by an insignificant true or false protrusion of eyeballs, a retraktion of an upper eyelid, lag of a century when lowering eyes, closed a century, gloss of eyes, insufficiency of convergence by a tremor.
Speak about an edematous ekzoftalm at a vystoyaniye of eyeballs on 25–30 mm, the expressed bilateral hypostasis of periorbitalny fabrics, a diplopiya, sharp limitation of mobility of eyeballs. Further progressing of an endocrine ophthalmopathy is followed by a full oftalmoplegiya, a nesmykaniye of eye cracks, hemozy conjunctivas, cornea ulcers, developments of stagnation at an eye bottom, pains in an orbit, a venous staz. In a clinical current of an edematous ekzoftalm allocate phases of compensation, subcompensation and a decompensation.
At an endocrine myopathy the weakness more often than direct glazodvigatelny muscles leading to a diplopiya, impossibility of assignment of eyes of a knaruzha and up, to squint, an eyeball deviation from top to bottom takes place. Owing to a hypertrophy of glazodvigatelny muscles their collagenic degeneration progressiruyushche accrues.
For designation of expressiveness of an endocrine ophthalmopathy in Russia are usually used V. G. Baranov's classification according to which allocate 3 degrees of an endocrine ophthalmopathy. Serve as criteria of an endocrine ophthalmopathy of 1 degree: not expressed (15,9 mm), moderate puffiness a century. Conjunctiva fabrics at the same time of an intaktna, function of glazodvigatelny muscles is not broken. The endocrine ophthalmopathy 2 degrees is characterized moderately expressed ekzoftalmy (17,9 mm), the considerable hypostasis a century expressed by conjunctiva hypostasis, periodic doubling. At an endocrine ophthalmopathy 3 degrees come to light the expressed signs of an ekzoftalm (20,8 mm and more), a diplopiya of resistant character, impossibility of a full smykaniye a century, an ulceration of a cornea, the phenomenon of an atrophy of an optic nerve.
Symptoms of an endocrine ophthalmopathy
Passing feelings of "sand" and pressure in eyes, dacryagogue or dryness of eyes, a photophobia, puffiness of periorbitalny area belong to early clinical displays of an endocrine ophthalmopathy. Further develops which has asymmetric or unilateral character in the beginning.
At a stage of the developed clinical manifestations the called symptoms of an endocrine ophthalmopathy become constants; noticeable increase in a vystoyaniye of eyeballs, an injection of a conjunctiva and skler, a swelling a century, a diplopiya, headaches is added to them. The impossibility of a full smykaniye leads a century to formation of ulcers of a cornea, development of conjunctivitis and an iridotsiklit. Inflammatory infiltration of plaintive gland is aggravated with a syndrome of a dry eye.
At the expressed ekzoftalm there can be a compression of an optic nerve leading to its subsequent atrophy. Ekzoftalm at an endocrine ophthalmopathy it is necessary to differentiate with psevdoekzoftalmy, observed at high degree of short-sightedness, orbital cellulitis (eye-socket phlegmon), tumors (gemangioma and sarcomas of an orbit, meningioma, etc.).
Mechanical restriction of mobility of eyeballs leads to increase in intraocular pressure and development, so-called, pseudo-glaucomas; in certain cases occlusion of veins of a retina develops. Involvement of eye muscles quite often is followed by development of squint.
Diagnosis of an endocrine ophthalmopathy
The diagnostic algorithm at an endocrine ophthalmopathy assumes inspection of the patient by the endocrinologist and ophthalmologist with performance of a complex of tool and laboratory procedures. Endocrinological inspection is directed to specification of function of a thyroid gland and includes a research of tireoidny hormones (free T4 and T3), antibodies to tissue of a thyroid gland (At to a tireoglobulin and At to a tireoperoksidaza), performing ultrasonography of a thyroid gland. In case of identification of knots of a thyroid gland with a diameter more than 1 cm, performance of a punktsionny biopsy is shown.
Ophthalmologic inspection at an endocrine ophthalmopathy pursues the aim of specification of visual function and visualization of structures of an orbit. The functional block includes a vizometriya, perimetry, a convergence research, electrophysiological researches. Biometric researches of an eye (an ekzoftalmometriya, measurement of a corner of squint) allow to determine height of a vystoyaniye and degree of a deviation of eyeballs.
For an exception of development of neuropathy of an optic nerve the eye bottom is examined (oftalmoskopiya); for the purpose of assessment of a condition of structures of an eye – biomicroscopy; for detection of intraocular hypertensia the tonometriya is carried out. Visualization methods (ultrasonography, MPT, KT of orbits) allow to differentiate an endocrine ophthalmopathy from tumors of retrobulbarny cellulose.
At an endocrine ophthalmopathy inspection of immune system of the patient is represented extremely important. Changes of cellular and humoral immunity at an endocrine ophthalmopathy it is characterized by decrease in number of CD3+ of T-lymphocytes, change of a ratio of CD3+ and lymphocytes, reduction of quantity of CD8+T-cynpeccopov; increase of the IgG level, anti-nuclear antibodies; increase in a caption of At to TG, TPO, AMAB (eye muscles), the second colloidal anti-gene. According to indications the biopsy of the affected glazodvigatelny muscles is carried out.
Treatment of an endocrine ophthalmopathy
Medical tactics is defined by a stage of an endocrine ophthalmopathy, extent of dysfunction of a thyroid gland and reversibility of pathological changes. All options of treatment are directed to achievement of an eutireoidny state. Pathogenetic immunosupressivny therapy of an endocrine ophthalmopathy includes purpose of the glucocorticoids (Prednisolonum) having antiedematous, anti-inflammatory and immunosupressivny effect. Corticosteroids are applied in and in the form of retrobulbarny injections.
At threat of loss of sight X-ray therapy of orbits is carried out puls-Yoterapiya by methylprednisolonum. Use of glucocorticoids is contraindicated at stomach ulcer of a stomach or duodenum, pancreatitis, thrombophlebitises, arterial hypertension, violation of coagulability of blood, mental and oncological diseases. As the methods supplementing immunosupressivny therapy serve the plasma exchange, haemo sorption, immunosorption, . In the presence of dysfunction of a thyroid gland correction of a tirostatikama (is carried out it at a thyrotoxicosis) or tireoidny hormones (at a hypothyroidism). At impossibility of stabilization of function of a thyroid gland performance of a tireoidektomiya from the subsequent ZGT can be required.
Symptomatic therapy at an endocrine ophthalmopathy is directed to normalization of metabolic processes in fabrics and neuromuscular transmission. Injections of an aktovegin, a prozerin, instillation of drops, a mortgaging of ointments and gels, reception of vitamins A and E are for this purpose appointed. From physical therapy methods at an endocrine ophthalmopathy the electrophoresis with lidazy or an aloe, magnetotherapy on area of orbits is used.
Possible surgical treatment of an endocrine ophthalmopathy includes three types of ophthalmologic operations: a decompression of an orbit, glazodvigatelny muscle operation, operation on centuries. The decompression of an orbit is directed to increase in volume of an eye-socket and shown at the progressing neuropathy of an optic nerve, the expressed ekzoftalm, cornea ulcerations, an eyeball incomplete dislocation, etc. situations. The decompression of an orbit (orbitotomiya) is reached by a resection of one or several of its walls, removal of retrobulbarny cellulose.
Surgeries on glazodvigatelny muscles are shown at development by a rack of a painful diplopiya, paralytic squint if he does not manage to be skorrigirovat prismatic points. Operations on centuries represent big group of various plastic and functional interventions which choice is dictated by the developed violation (a retraktion, a spastic zavorot, lagoftalmy, a prolapse of plaintive gland, hernia with loss of orbital cellulose and so forth).
Forecast of an endocrine ophthalmopathy
In 1-2% of cases especially heavy course of an endocrine ophthalmopathy leading to heavy visual complications or the residual phenomena is observed. Timely medical intervention allows to achieve the induced remission and to avoid serious consequences of a disease. As result of therapy at 30% of patients serves clinical improvement, at 60% - stabilization of a course of an endocrine ophthalmopathy, at 10% - further progressing of a disease.