Frequency of Thyrotoxicosis in Patient with One Sided Exophthalmos

Authors’ Contributions 1 Conception & study design 3 Data Collection & Processing 4 Data Analysis and/or Interpretation 2 Drafting of Manuscript 5 Critical Review Article info. Received: October 25, 2019 Accepted: September 10, 2020 Funding Source: Nil Conflict of Interest: Nil Cite this article: Zafar T, Perveen S, Khan N, Khan S, Ahmed T. Frequency of Thyrotoxicosis in Patient with One Sided Exophthalmos. RADS J Pharm Pharm Sci. 2020; 8(2):81-84. *Address of Correspondence Author: tahseen.channa89@gmail.com Background: Thyroid associated Opthalmo-pathy is a condition of lid retraction causing a staring appearance. This occurs in any form of thyrotoxicosis as a result of sympathetic overactivity.Exophthalmos is the forward protrusion of eye ball beyond the orbital rim. Material & Methods: This case series was observed in medical department Mufti Mehmood Teaching Hospital DIKhan, Pakistan over a period of eight months from February 2018 to September 2018. Detailed history with reference of duration of illness, mode of onset, progression and associated symptoms like fever, pain, diplopia and loss of vision was taken. Complete examination of orbit, eyelid, anterior and posterior segment was done. Routine Investigations along with special diagnostic tests like TFTs and MRI were performed to aid etiological diagnosis. Results: A total 47 patients were observed during this study period. Out of these 20 (21.27%) were male and 27 (57.44%) were female with male to female ratio 1:1.35 with mean age of 32 years. Out of 47 patients30 (63.82%) patients were having thyrotoxicosis as a cause of exophthalmos, 10(21.27%) were having retrobulbartumour, 5(10.63%) patients were with cavernous sinus thrombosis and 2(4.25%) patients were having idiopathic cause of exophthalmos. Conclusion: Thyrotoxicosis is the common cause of one sided exophthalmos and should be considered in all patients with one sided exophthalmos.


I N T R O D U C T I O N
Thyroid associated Opthalmo-pathy is a condition of lid retraction causing a staring appearance. This occurs in any form of thyrotoxicosis as a result of sympathetic overactivity [1]. Proptosis is the forward movement of the globe in relation to the skull whereas Henderson reserves the use of word exophthalmos for those cases of Proptosis secondary to endocrinological dysfunction. The exact clinical diagnosis of proptosis's cause is difficult due to inaccessibility of the contents of orbit. [2] In 5-10% of the cases severe exophthalmos occur due to increased retro-orbital fat and lymphocytic infiltration of extraocular muscles. Proptosis is usually bilateral but can be unilateral (10%) and is measured by using Hertel Exophthalmometer. The normal value of protrusion is 21mm in white men and 19mm in white women, 24mm in black men and 23mm in black women, 19.9mm in Asian men and 18.6mm in Asian women RADS J. Pharm. Pharm. Sci. 82 [3]. Theincidence of exophthalmos is 16/100,000 in women and 3/100,000 in men per year. Study shows that prevalence of exophthalmos is higher in Europeans at a rate of 42% versus 7.7% in Asians. Europeans are 6.4 times more prone to have Grave's Opthalmo-pathy [4]. Thyroid eye disease is the most common cause of unilateral and bilateral Proptosis. This disease is present in almost 50% of Graves disease cases and 5% patients develop severe diseases with dysthyroid optic neuropathy. Some other causes of Proptosis arecellulitis,mucormycosis, retro orbital tumors and cavernous sinus thrombosis. Pathogenesis of thyroid eye disease derives from a complex interplay of endogenous and exogenous factors, where the former is a non-modifiable factor while the latter can be modified [5,6].
It has been observed that preventive actions such as quitting smoking may (up to some extent) prevent progression and severity of graves' orbito-pathy. Studies also show that graves' orbitopathy is best treated by immuno-suppression when active or by surgery in an inactive scenario. Additionally, some patients may require rehabilitative surgery (e.g. orbital decompression and/or eyelid surgery) when the disease course ends. The aim of this study was to know the frequency of thyrotoxicosis and other causes of one sided exophthalmos and treatable causes should be sort out and treated.

M A T E R I A L S A N D M E T H O D S
This case series was observed at Medical Department Mufti Mehmood Teaching Hospital DIKhan, Pakistan over a period of eight monthsfrom February 2018 to September 2018. Patients with one sided exophthalmos were included in this study. Patients with bilateral exophthalmos and other ophthalmic problem were excluded from the study.Detailed history with reference of duration of illness, mode of onset, progression and associated symptoms like fever, pain, diplopia and loss of vision was taken. Complete examination of orbit, eyelid, anterior and posterior segment was done. Routine Investigations along with special diagnostic tests like TFTs and MRI were performed to aid etiological diagnosis.

D I S C U S S I O N
Thyroid eye disease is a functionally debilitating disease seen all over the world often disfiguring and impairing quality of life. Most studies in world have shown a raised female to male ratio of patients primarily affected by thyroid eye disease. In our study it was observed that female gender was primarily affected more by Thyroid eye disease with a ratio of 1:1.35. A study from Iran by Sara Gharib et al [7] reported this ratio as 1:1.7. A study by M.L Tanda et al [8] had a ratio of 1:3 having mild grave's orbitopathy. A study by NithinTenja et al [9] had a ratio of 1:1.07. Besharti, Etezad-Razavi & Perros also showed a higher frequency in females [10][11][12]. It is obvious from the results of this study that young age group with a mean age of 32 year are the main sufferer of one sided exophthalmos. It is consistent with many other studies. Sara Gharib et al [7] reported the mean age of 35 (standard deviation 13.0). M.L. Tanda et al [8] reported the mean age of 45.7 + 13.7years. In our study thyrotoxicosis was seen as the most common cause of one sided exophthalmos (63.8%) similar to the study conducted by NithinTeja et al in which thyrotoxicosis and inflammation were the top most causes of one sided exophthalmos. This however is in contrast to the observations of Masud et al [13] where they showed tumor as the most common cause of Proptosis. Among all patients of Proptosis 21.2% were having retrobulbar tumor which is almost similar to NithinTeja et al [9] (18.51%) where as in Masud et al [13] study it was 33%. Cavernous sinus thrombosis is the formation of blood clot with in cavernous sinus, a cavity at base of brain which drains deoxygenated blood from brain back to heart. Cavernous sinus thrombosis was observed in 10.6% in our study where as in study of NithinTeja et al it was only 5.5%. Unilateral Proptosis of unexplained origin may be due to small mass in muscles cone not extending to orbital apex as a simple tumor, cyst or reactive hyperplasia. In our study idiopathic causes were observed in 2(4.2%) patients similar to the study done by Blegvad that reported 5 cases with idiopathic causes and Gleason also reported a case of idiopathic cause of one sided exophthalmos. Duke-Elder (1952) prefers to classify it with exophthalmic ophthalmoplegia due to thyroid pituitary disorder. If, during orbital exploration to discover the cause of exophthalmos, nothing is found, a biopsy of the rectus muscle should be taken to exclude dysthyroidism [14][15][16][17][18][19].

C O N C L U S I O N
Thyrotoxicosis is the commonest cause of one sided exophthalmos. It is recommended to investigate the thyrotoxicosis in all cases of exophthalmos. All the patients with one sided exophthalmos should be advised MRI Brain to look for other causes of exophthalmos. The study also indicates that female and people of younger age group are more involved in thyroid eye disease.