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Eye disease restricted to one eye as assessed by physical examination was observed in 11% of our patients. Although it is well known that GO is the single most common cause of unilateral proptosis (approximately 15%-28% of cases)[25, 26], few data are available on the prevalence of unilateral localization in a sample of patients with GO. The reported occurrence varies between 5% and 11.6%[27, 28]. Interestingly, evidence has been put forward demonstrating involvement of the fellow eye in cases of unilateral GO[24]. Our data on age, sex distribution and eye changes also indicates that patients with unilateral GO belong to the same population as those with bilateral eye disease. The occurrence of clinically evident thyroid disease was not significantly lower in patients with unilateral than in those with bilateral eye, but the interval between the onset of thyroid disease and eye disease was much shorter in unilateral ophthalmopathy. This might simply indicate that unilateral GO is an early stage of the disease. The absence of a clear preference for the left or right eye in unilateral GO negates an important role of local factors and is compatible with the systemic nature of Graves' disease.
The ophthalmological presentation in patients without clinically evident thyroid disease was not different from that in patients with thyroid disease (Table 4). The slightly but not significantly higher number of patients with unilateral eye disease in the subgroup without clinically evident thyroid disease is again indicative for an early stage of Graves' disease in these subjects. In our study 15 patients (14.5%) had intraocular pressure of higher than 22. Of the 103 patients, 17 (15.8%) exhibited typical glaucomatous visual field defects in automatic static threshold perimetry in the absence of compressive optic neuropathy. The intraocular pressure in 7 of the 17 patients was consistently less than 22mm Hg during the follow-up period. Thus, these patients were diagnosed as having normal-tension glaucoma. Of the 103 patients, 22 (21%) were diagnosed as having glaucoma associated with GO. These finding is similar to the finding of Ohtsuka and Nakamura et al [29], and Cockerham et al [30].
A small number of patients are at risk of blindness as a result of severe exophthalmos, inability to completely appose the eyelids and subsequent risk of corneal ulceration and infection, or as a result of optic neuropathy caused by optic nerve compression by the swollen eye muscles at the apex of the orbit. The latter is associated with reduced visual acuity, loss of color vision, reduced visual fields, relative afferent pupillary defect and papilloedema. In our patients causes of visual loss were as follows; 6 patients due to optic neuropathy, 3 due to corneal ulcer, and 5 due to glaucoma. We did not find any significant associations between GO and concomitant systemic disorders. Diabetes mellitus occurred in only 3 (2.9%) of the 103 patients, which appears to be the same as expected based on prevalence rate of diabetes (2.71%) as determined by Melton and associates[31]. Although association of hyperthyroidism and myasthenia gravis, and GO has been recognized for many years, but in our study no patient had myasthenia gravis. In another study Brain reported the presence of several miscellaneous conditions, including persistent lactation and gynecomastia lipodystrophy[32], of idiopathic thrombocytopenic purpura[33] and generalized edema, in patients with GO. In Another study correlation between pernicious anemia and Graves' disease has been reported[34]. No such associations were found among our patients.
Our study concluded a significant number of the thyroid patients that are referred to our hospital. Because of the referral of these patients, it is possible that only complicated cases be referred, so that it can be one of the possible causes of selection bias in this study. On the other hand lack of good follow-up is a drawback in our study. Lastly, our study findings are compatible in frequency of signs and symptoms, and sight threatening complications of GO, except for demographic distribution especially between male and female. Authors of this article suggest a large prospective study to confirm any difference in clinical manifestation of GO between Iranian patients and other reported countries.
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