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Fulltext A report of three cases of untreated Graves' disease associated with pancytopenia in Malaysia

Rafhati AN, See CK, Hoo FK, Badrulnizam LB

Electron Physician, 2014;6(3):877-82.
PMID: 25763162 DOI: 10.14661/2014.877-882

Generally, clinical presentations of Graves' disease range from asymptomatic disease to overt symptomatic hyperthyroidism with heat intolerance, tremor, palpitation, weight loss, and increased appetite. However, atypical presentation of Graves' disease with hematological system involvement, notably pancytopenia, is distinctly uncommon. Hereby, we present and discuss a series of three untreated cases of Graves' disease clinically presented with pancytopenia and the hematological abnormalities that responded well to anti-thyroid treatment. With resolution of the thyrotoxic state, the hematological parameters improved simultaneously. Thus, it is crucial that anti-thyroid treatment be considered in patients with Graves' disease and pancytopenia after a thorough hematological evaluation.

Matched MeSH terms: Graves Disease*
Fulltext Neonatal Outcomes of Pregnancies Complicated by Maternal Hyperthyroidism

Abdullah AA, Ramli N, Yaacob NM, Hussain S

J ASEAN Fed Endocr Soc, 2022;37(2):15-22.
PMID: 36578895 DOI: 10.15605/jafes.037.02.03

OBJECTIVE: This study aimed to determine the proportion, clinical characteristics, hormonal status, median time for normalization of serum thyroxine (FT4) and thyroid-stimulating hormone (TSH) and factors affecting time to thyroid function test (TFT) normalization of neonates born to mothers with maternal hyperthyroidism admitted in our institution.
METHODOLOGY: This was a retrospective cohort study that included 170 newborns admitted to the Neonatal Intensive Care Unit (NICU) of Hospital Universiti Sains Malaysia (HUSM) with a history of maternal hyperthyroidism from January 2013 until December 2018. We analyzed their baseline demographic and clinical characteristics, maternal thyroid status and antibody levels. Finally, we analyzed newborn thyroid function and thyroid antibodies.
RESULTS: The proportion of neonates born to mothers with maternal hyperthyroidism was 0.8% (170 of 20,198 neonates within the study period). Seven (4.1%) developed overt hyperthyroidism, while four (2.4%) had thyroid storm. The median time for thyroid function test normalization was 30 days (95% CI: 27.1 to 32.8). The median time for TFT normalization was longer among neonates of mothers with positive thyroid antibodies [46.6 days (95% CI, 20.6 to 39.4)] and of mothers who received anti-thyroid treatment [31.7 days (95% CI, 23.5 to 39.9)].
CONCLUSION: Neonates born to mothers with hyperthyroidism is uncommon. These babies were observed to have a longer time for normalization of thyroid function tests if their mothers had thyroid antibodies or received anti-thyroid treatment.

Matched MeSH terms: Graves Disease*
Fulltext Radioiodine I-131 for the therapy of graves' disease

Mumtaz M, Lim SL, Khaw CH, Mohd Khir AS

Malays J Med Sci, 2009 Jan;16(1):25-33.
PMID: 22589645

Graves' disease is a common cause of hyperthyroidism. Treatment options for Graves' disease include antithyroid medication, surgery or radioactive iodine (I-31) or RAI. This review will focus on the approach to RAI therapy; discussing dose selection, patient preparation, and consideration before and after administering RAI, examining aspects of pre-treatment with antithyroid medication as well as discussing possible adverse events including hypothyroidism and possible worsening of thyroid-associated opthalmopathy. Follow-up is lifelong with the aim of ensuring the patient remains euthyroid or on replacement therapy if there is evidence of hypothyroidism. While there are controversies in treatment of thyrotoxicosis with RAI, with appropriate patient selection and regular follow-up, radioiodine is a safe and effective modality in achieving high cure rates.

Matched MeSH terms: Graves Disease*
Fulltext Pancytopenia in a patient with Grave's disease

Loh HH, Tan F

Med J Malaysia, 2013 Aug;68(4):372-3.
PMID: 24145274 MyJurnal

Pancytopenia can rarely complicate Grave's disease. It can be due to uncontrolled thyrotoxicosis or as a result of rare side effect of antithyroid medication. Pernicious anemia leading to Vitamin B12 deficiency is another rare associated cause. We report a case of a patient with Grave's disease and undiagnosed pernicious anemia whom was assumed to have antithyroid drug induced pancytopenia. Failure to recognize this rare association of pernicious anemia as a cause of pancytopenia had resulted in delay in treatment and neurological complication in our patient.

Matched MeSH terms: Graves Disease*
Refractory hypothyroidism

Lai YY, Thambiah SC, Mohamed Mokhtar N, Samsudin IN

Malays J Pathol, 2024 Apr;46(1):109-113.
PMID: 38682851

INTRODUCTION: Persistently elevated thyroid stimulating hormone (TSH) despite levothyroxine (LT4) treatment that exceeds the standard weight-adjusted dose is a common clinical presentation. This may lead to additional testing for LT4 malabsorption or poor LT4 adherence, the latter of which is challenging to confirm because it is predicated on accurate patient accountability.
CASE REPORT: A 35-year-old lady, post-radioactive iodine therapy for Graves' disease remained euthyroid for a year on oral LT4. Two years later, she was clinically and biochemically hypothyroid despite claiming LT4 compliance. As all laboratory investigations were within the reference range, pseudomalabsorption was suspected and a LT4 absorption test was done. During the test, her free thyroxine increased significantly at 4 hours, reaching a peak of more than 50% from baseline while TSH decreased appropriately from 0 minute to 360 minutes. This was followed by normalisation of TSH with LT4 treatment under direct observation.
DISCUSSION: The LT4 absorption test is a prompt and economical means to rule out true malabsorption, decrease unwarranted subspecialty referrals and validate the weight-adjusted LT4 dose reduction.

Matched MeSH terms: Graves Disease/drug therapy
Fulltext Hyperthyroid graves disease--a 5 year retrospective study

Tan TT, Ng ML, Wu LL, Khalid BA

Med J Malaysia, 1989 Sep;44(3):224-30.
PMID: 2626137

The clinical, biochemical and immunological features of 180 patients with hyperthyroid Graves' disease managed at the Universiti Kebangsaan Malaysia (UKM) Endocrine Clinic from 1983 to 1987 were examined. The prevalence of the disease is highest in Chinese and lowest in Indians. The female: male ratio is 2.8:1. Hypokalaemic periodic paralysis and hypercalcaemia were present in 5.0% and 1.7% of the cases respectively. Pretibial myxoedema was extremely rare. Thyrotropin - binding inhibitory immunoglobulins, anti-thyroglobulin and anti-microsome antibodies were positive in 61.5%, 25.8% and 42.3% of the patients respectively. A eumetabolic state could be achieved in the majority of patients with antithyroid drugs alone. Definitive therapy with subtotal thyroidectomy or radioiodine were needed in 31.3% of cases.

Matched MeSH terms: Graves Disease/diagnosis*; Graves Disease/epidemiology; Graves Disease/therapy
Management strategies in Graves' hyperthyroidism

Tan CE, Tan KT, Khoo D, Wang KW

Family Physician, 1991;3:42-45.

Antithyroid drugs, radioiodine and surgery are lhe three modalities of treatment for Graves' hyperthyroidism. The treatment strategy depends on a clear understanding of the relative advantages and disadvantages of each mode of treatment as well as the individual patient's preference. Recent studies favour the use of high dose antithyroid drugs with thyroxine supplementation to induce a higher rate of remission. Radioiodine is likely to be favoured as the definitive form of treatment. Surgery still has a place particularly for young female patients with large goitres. Keywords: Antithyroid drugs, radioiodine, thyroidectomy.

Matched MeSH terms: Graves Disease
Fulltext Dual thyroid ectopia with graves' disease: a case report and a review of the literature

Tan TH, Lee BN, Amir Hassan SZ, Ch'ng ES, Hussein Z

Nucl Med Mol Imaging, 2012 Dec;46(4):300-3.
PMID: 24900078 DOI: 10.1007/s13139-012-0160-x

Ectopic thyroid or thyroid ectopia is a rare developmental anomaly with the prevalence of 1 per 100,000-300,000 population. Even rarer, such an anomaly manifests as dual thyroid ectopia. To our best knowledge, only one case has been reported on dual thyroid ectopia with Graves' disease in the English literature. We present here a case of dual thyroid ectopia complicated by Graves' disease, whereby the diagnosis was rendered through judicious use of various diagnostic modalities coupled with a close clinical follow-up. In this case, therapeutic consideration should be personalized with proper informed consent of the patient.

Matched MeSH terms: Graves Disease*
Fulltext Radiation doses to patient's relatives following radioiodine therapy

Sulaiman BT, Clarke SE

Med J Malaysia, 1996 Mar;51(1):131-3.
PMID: 10967992

A total of 10 volunteers were monitored for radiation doses, whose spouses were given radio-iodine (131I) orally. Nine of the spouses were given radio-iodine for Graves' disease and one for thyroid carcinoma. It was found that the highest radiation dose received by the volunteer was only 13.5% of the annual dose limit for individual members of the public. Hence, patients treated with radio-iodine do not pose a significant radiation hazard to the public.

Matched MeSH terms: Graves Disease/radiotherapy*
Fulltext Gut Microbiome Associated With Graves Disease and Graves Orbitopathy: The INDIGO Multicenter European Study

Biscarini F, Masetti G, Muller I, Verhasselt HL, Covelli D, Colucci G, et al.

J Clin Endocrinol Metab, 2023 Jul 14;108(8):2065-2077.
PMID: 36683389 DOI: 10.1210/clinem/dgad030

CONTEXT: Gut bacteria can influence host immune responses but little is known about their role in tolerance-loss mechanisms in Graves disease (GD; hyperthyroidism caused by autoantibodies, TRAb, to the thyrotropin receptor, TSHR) and its progression to Graves orbitopathy (GO).
OBJECTIVE: This work aimed to compare the fecal microbiota in GD patients, with GO of varying severity, and healthy controls (HCs).
METHODS: Patients were recruited from 4 European countries (105 GD patients, 41 HCs) for an observational study with cross-sectional and longitudinal components.
RESULTS: At recruitment, when patients were hyperthyroid and TRAb positive, Actinobacteria were significantly increased and Bacteroidetes significantly decreased in GD/GO compared with HCs. The Firmicutes to Bacteroidetes (F:B) ratio was significantly higher in GD/GO than in HCs. Differential abundance of 15 genera was observed in patients, being most skewed in mild GO. Bacteroides displayed positive and negative correlations with TSH and free thyroxine, respectively, and was also significantly associated with smoking in GO; smoking is a risk factor for GO but not GD. Longitudinal analyses revealed that the presence of certain bacteria (Clostridiales) at diagnosis correlated with the persistence of TRAb more than 200 days after commencing antithyroid drug treatment.
CONCLUSION: The increased F:B ratio observed in GD/GO mirrors our finding in a murine model comparing TSHR-immunized with control mice. We defined a microbiome signature and identified changes associated with autoimmunity as distinct from those due to hyperthyroidism. Persistence of TRAb is predictive of relapse; identification of these patients at diagnosis, via their microbiome, could improve management with potential to eradicate Clostridiales.

Matched MeSH terms: Graves Disease*
Insulin-like growth factor-binding protein-3 (IGFBP-3) but not insulin-like growth factor-I (IGF-I) remains elevated in euthyroid TSH-suppressed Graves' disease

Wan Nazaimoon WM, Khalid BA

Horm. Metab. Res., 1998 Apr;30(4):213-6.
PMID: 9623636 DOI: 10.1055/s-2007-978868

Thyroid hormones have been shown to be involved in the regulation of insulin-like growth factor-I (IGF-I) and IGF binding protein-3 (IGFBP-3) expression. This is a cross-sectional study to look at the effects of thyroid hormone status on the circulating levels of IGF-I and IGFBP-3 in a group of 127 patients, aged 20-80 years, who were hyperthyroid, hypothyroid, rendered euthyroid and clinically euthyroid with normal free thyroxine (fT4), but suppressed thyroid stimulating hormone (TSH) levels. TSH was measured by the IMx (Abbott) ultrasensitive assay, while radioimmunoassays for total T3 and T4 were performed using kits from ICN, USA; fT4 and fT3 using kits from DPC USA; IGF-I and IGFBP-3 using kits from Nichols Institute Diagnostics B.V., Netherlands. Differences in the levels of IGF-I between the 4 groups of patients were significant only in the patients aged 20-40. Mean (+/-SEM) IGF-I levels of hypothyroid patients (169+/-19ng/ml) was significantly lower than hyperthyroid (315+/-26 ng/ml, p=0.003), euthyroid patients (241+/-19 ng/ml, p=0.002) and patients with suppressed TSH (308+/-29 ng/ml, p=0.02). The IGF-I levels of the hyperthyroid and suppressed TSH patients were, however, comparable to age-matched normal subjects (281+/-86 ng/ml). Although there was no difference in mean IGFBP-3 levels between the 4 groups of patients, the levels in the patients aged 20-40 with hyperthyroidism (3.7+/-0.9 microg/ml) and suppressed TSH (3.9+/-1.2 microg/ml) were significantly higher (p=0.02) than age-matched normal subjects (3.1+/-0.8 microg/ml). The IGF-I levels of the thyroid patients aged 20-40 showed significant negative correlation to TSH and positive correlations to the thyroid hormones. Hence, whilst low IGF-I is associated with hypothyroidism, high IGFBP-3 is associated with hyperthyroidism. Our finding that IGFBP-3 remained significantly elevated in patients with suppressed TSH but normalised fT4 and fT3 is important as it suggests a prolonged tissue effect of thyroid hormones on IFGBP-3. As such patients have been shown to have higher risk for atrial fibrillation, the significance and possible role of IGFBP-3 in these conditions should be further elucidated in future studies.

Matched MeSH terms: Graves Disease/blood; Graves Disease/physiopathology*
Fulltext A case of Hashimoto encephalopathy in a Malay woman with Graves disease

Ngiu CS, Ibrahim NM, Yahya WN, Tan HJ, Mustafa N, Basri H, et al.

BMJ Case Rep, 2009;2009.
PMID: 21709844 DOI: 10.1136/bcr.01.2009.1501

Hashimoto encephalopathy (HE) is a poorly recognised steroid-responsive encephalopathy, with prominent neuropsychiatric features. Diagnosis is often difficult due to its heterogeneous clinical presentation, especially since the thyroid status or anti-thyroid antibody titres may not be related to the disease state. Here, the case of a 23-year-old Malay woman with Graves disease who presented with progressive encephalopathy diagnosed as HE is presented. She responded dramatically to high dose intravenous and then oral corticosteroid. A month after the initiation of treatment, she regained full independency.

Matched MeSH terms: Graves Disease
Prevalence, risk factors, and clinical features of thyroid-associated ophthalmopathy in multiethnic Malaysian patients with Graves' disease

Lim SL, Lim AK, Mumtaz M, Hussein E, Wan Bebakar WM, Khir AS

Thyroid, 2008 Dec;18(12):1297-301.
PMID: 19012471 DOI: 10.1089/thy.2008.0044

The prevalence of thyroid-associated ophthalmopathy (TAO) has been reported to be lower in several Asian populations than in Caucasians. The risk factors for TAO that have been demonstrated in Caucasians have not been studied in Asian populations. The aim of this study, therefore, was to determine the prevalence, risk factors, and clinical features of TAO in a cohort of multiethnic Malaysian patients with Graves' disease (GD).

Matched MeSH terms: Graves Disease/diagnosis; Graves Disease/etiology; Graves Disease/epidemiology
Fulltext A combined case of macroprolactinoma, growth hormone excess and Graves' disease

Hussein Z, Tress B, Colman PG

Med J Malaysia, 2005 Jun;60(2):232-6.
PMID: 16114168

Thyrotoxicosis due to Graves disease is a relatively common endocrine disorder. The occurrence of a prolactinoma with co-secretion of growth hormone (GH) is on the other hand, rare. We report the rare co-existence of Graves' disease in a patient with macroprolactinoma and GH hypersecretion and describe the successful response to medical therapy with dopamine agonist and antithyroid therapy. We hypothesize that hyperprolactinaemia played a role in promoting autoimmune thyroid disease in our patient and that treatment of hyperprolactinaemia may have been important in suppressing autoimmune disease activity in Graves' disease. This case also reflects on the close and complex interactions between thyroid hormones, prolactin (PRL), GH and testosterone (T).

Matched MeSH terms: Graves Disease/blood; Graves Disease/complications*; Graves Disease/drug therapy
Usefulness and limitations of thyrotropin measurements as a first-line test for follow-up of Graves' patients

Ng ML, Tan TT, Roslan BA, Rajna A, Khalid BA

Ann Acad Med Singap, 1993 Jul;22(4):569-72.
PMID: 7504901

We evaluated the usefulness of sensitive thyrotrophin hormone (TSH) measurements in determining the thyroid status in the follow-up of Graves' patients undergoing medical treatment with thionamides. Out of a total of 186 serum samples tested, TSH levels were suppressed in 123 (66.1%), normal in 32 (17.2%) and elevated in 31 (16.7%) cases. Total T4, or T3 or both were elevated only in 97 (74.8%) cases of TSH-suppressed patients, indicating that TSH is less discriminatory as a first-line test for patients under treatment due to the hypothalamic-pituitary lag period. No comparisons with free T4 or free T3 were done in this study. Both total T4 (120 +/- 28 nmol/l) and TBII (23 +/- 21%) levels were significantly greater (p < 0.02) in the euthyroid group with suppressed TSH. This may suggest that persistence of a thyrotoxic state may still be present.

Matched MeSH terms: Graves Disease/diagnosis*; Graves Disease/drug therapy; Graves Disease/immunology
Fulltext Cerebral venous sinus thrombosis in a patient with concomitant Graves' disease and squamous cell carcinoma of the cervix

Chee YC, Abdul Halim S

BMJ Case Rep, 2020 Dec 09;13(12).
PMID: 33298481 DOI: 10.1136/bcr-2020-236730

Cerebral venous sinus thrombosis (CVST) is caused by either acquired or inherited pro-thrombotic states. Hyperthyroidism is a less recognised predisposing factor of CVST, and the causality has been debated. We report a case of a life-threatening CVST in a 40-year-old woman, with uncommon dual risk factors: hyperthyroidism and advanced squamous cell carcinoma of the cervix. CVST should be considered as a differential diagnosis when a patient with hyperthyroidism presents with new-onset headache or other neurological symptoms. Further assessment to elucidate other covert risk factors may need to be continuously carried out, when the causal relationship of one apparent cause has not been well established.

Matched MeSH terms: Graves Disease/complications*
Fulltext Association of DPP4 Gene Polymorphisms with Type 2 Diabetes Mellitus in Malaysian Subjects

Ahmed RH, Huri HZ, Al-Hamodi Z, Salem SD, Al-Absi B, Muniandy S

PLoS One, 2016;11(4):e0154369.
PMID: 27111895 DOI: 10.1371/journal.pone.0154369

BACKGROUND: Genetic polymorphisms of the Dipeptidyl Peptidase 4 (DPP4) gene may play a role in the etiology of type 2 diabetes mellitus (T2DM). This study aimed to investigate the possible association of single nucleotide polymorphisms (SNPs) of the DPP4 gene in Malaysian subjects with T2DM and evaluated whether they had an effect on the serum levels of soluble dipeptidyl peptidase 4 (sDPP-IV).
METHOD: Ten DPP4 SNPs were genotyped by TaqMan genotyping assays in 314 subjects with T2DM and 235 controls. Of these, 71 metabolic syndrome (MetS) subjects were excluded from subsequent analysis. The odds ratios (ORs) and their 95% confidence interval (CIs) were calculated using multiple logistic regression for the association between the SNPs of DPP4 and T2DM. In addition, the serum levels of sDPP-IV were investigated to evaluate the association of the SNPs of DPP4 with the sDPP-IV levels.
RESULTS: Dominant, recessive, and additive genetic models were employed to test the association of DPP4 polymorphisms with T2DM, after adjusting for age, race, gender and BMI. The rs12617656 was associated with T2DM in Malaysian subjects in the recessive genetic model (OR = 1.98, p = 0.006), dominant model (OR = 1.95, p = 0.008), and additive model (OR = 1.63, p = 0.001). This association was more pronounced among Malaysian Indians, recessive (OR = 3.21, p = 0.019), dominant OR = 3.72, p = 0.003) and additive model (OR = 2.29, p = 0.0009). The additive genetic model showed that DPP4 rs4664443 and rs7633162 polymorphisms were associated with T2DM (OR = 1.53, p = 0.039), and (OR = 1.42, p = 0.020), respectively. In addition, the rs4664443 G>A polymorphism was associated with increased sDPP-IV levels (p = 0.042) in T2DM subjects.
CONCLUSIONS: DPP4 polymorphisms were associated with T2DM in Malaysian subjects, and linked to variations in sDPP-IV levels. In addition, these associations were more pronounced among Malaysian Indian subjects.

Matched MeSH terms: Graves Disease/genetics; Graves Disease/epidemiology
Fulltext Clinical value of a rapid fully automated thyroid autoantibody assay in the diagnosis and management of graves disease

Hanita, O., Azura, N.R., Faizal, M.M.Z.

Medicine & Health, 2012;7(1):24-31.
MyJurnal

The most common cause of hyperthyroidism is Graves disease (GD) which is characterised by the presence of autoantibodies which binds to the TSH receptor (TRAb). Recently, a rapid, fully automated electrochemiluminescent immunoassay ElecsysAnti-TSHR for detection of autoantibodies to TSH receptor was made available for routine clinical use. The objective of this study is to evaluate this assay and to determine the sensitivity, specificity and cut-off value. Interassay and total imprecision (CV) were determined at 3.78-7.02 IU/L and 13.5-21.2 IU/L respectively. A total of 124 samples which comprised of 46 GD, seven Hashimoto thyroiditis (HD), 11 non autoimmune nodular goitre (NAG), 2 thyroid cancers (Ca) and 58 normal controls were retrospectively analysed to determine the sensitivity, specificity and cut-off value. Inter-assay CV’s were 2.4% at a concentration of 3.90 IU/L (range: 3.78-7.02 IU/l) and 0.8% at 20.80 IU/L (range:13.5-21.2 IU/l). Total imprecision was 3.8% at a concentration of 3.80 IU/L (range:13.5-21.2 IU/l) and 1.0% at 20.8 IU/L (range:13.5-21.2 IU/l). The ROC analysis of patients with GD, other thyroid disorders and normal controls revealed that the highest sensitivity (94%) and specificity (98%) were seen at cut-off value of 1.69 IU/L. Positive predictive value (PPV) and negative predictive value (NPV) was 95% and 94% respectively. At this derived cut-off value of 1.69 IU/L, we found that the sensitivity of TRAb positivity within the group of 29 newly diagnosed GD patients was 94%. Our results demonstrate that this fully automated assay with testing time of 27 minutes has high sensitivity in detecting GD and high specificity for discriminating other thyroid disease and represent major improvement in the diagnosis and management of patients with thyroid diseases.

Matched MeSH terms: Graves Disease
Fulltext Weathering the Crisis: A Case of Thyroid Crisis with Propranolol-Induced Circulatory Collapse Successfully Treated with Therapeutic Plasma Exchange

Cheah JM, Ng D, Low MY, Foo SH

J ASEAN Fed Endocr Soc, 2019;34(2):206-209.
PMID: 33442157 DOI: 10.15605/jafes.034.02.12

Thyroid crisis is a life-threatening form of thyrotoxicosis characterized by multi-system dysfunction. Therapeutic plasma exchange has been reported to be effective in removing excessive circulating thyroid hormones. We present a 46-year-old female with recently diagnosed Graves' disease associated with thyrotoxic cardiomyopathy admitted for thyroid crisis complicated by propranolol-induced circulatory collapse, acute kidney injury and ischemic hepatitis. The tachyarrhythmia was refractory to conventional therapy. Initiation of TPE resulted in rapid clinical and biochemical stabilization.

Matched MeSH terms: Graves Disease
Thyroid eye disease--medical or surgical therapy?

Khalid BA, Ng ML

Ann Acad Med Singap, 1991 Mar;20(2):273-6.
PMID: 1883189

Thyroid eye disease is autoimmune in nature and associated with Graves' Disease. Autoantibodies to the 64 kDa antigen in thyroid membranes cross-react to the 64 kDa proteins in human eye muscle membranes. Antibody dependent cell mediated cytotoxicity against eye muscle cells are also found in patients with thyroid eye disease. The purpose of this paper is to review the treatment available and to share the authors' experience using cyclosporin A. In the majority of cases, thyroid eye disease is mild, manifest only as bilateral or unilateral proptosis, with/without grittiness of the eyes. This is usually treated conservatively with eye drops. If proptosis is more severe and there is incomplete closure of eyelids, epiphora and conjunctival injection, then lateral tarrsorrhaphy is usually effective, combined with use of eye pads and eye drops. The problem of diplopia can be treated conservatively with special lenses, or with surgical correction of tethered muscles. However when proptosis is severe, with raised intraocular pressure, severe chemosis and danger of blindness, then the choice of therapy is controversial: rapid decompression by surgical means or use of high doses of prednisolone. Most prefer prednisolone therapy initially, surgical decompression if it fails. Various other methods have been tried, aimed at the immunological nature of the disease, namely plasmapheresis, radiotherapy and immunosuppressive drugs such as cyclosporin, with variable success. Our experience with cyclosporin had been mixed and inconclusive.

Matched MeSH terms: Graves Disease/complications*

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