1ClinicalfeaturesofGravesophthalmopathyinIranAliSadeghiTari,MohammadTaherRajabi,KhalilHamzedust,SeyedZiaeddinTabatabaie,AbolfazlKasaiAbstractAIM:TodeterminetheclinicalcharacteristicsofaprospectivestudyofpatientswithGravesophthalmopathy.METHODS:Wereviewedclinicalmanifestations,andmedicalrecordsof103patientsinwhomGravesophthalmopathywasdiagnosedbetween2003and2005.RESULTS:Among103patientswithGravesophthalmopathy,48(46.6%)maleand55(53.3%)female(F:M=1.1),withmeanageof45(range;18-73)years,95(92.2%)patientshadGraveshyperthyroidism,3(2.9%)hadprimaryhypothyroidism,and5(4.8%)wereeuthyroid.Themeandurationofocularsymptomswas13.2(range2-95)months)whilethemeandurationofdysthyroidsymptomswas39.4(range6-180)months.Unilateralitywasoccurredin12patients.Eyelidretractionwaspresentin90patients(87%),whereastheapproximatefrequencyofexophthalmoswas77.6%(80patients);restrictiveextraocularmyopathy,29%(30patients);evidenceofextraocularenlargementonCT-scanin52patientsof70patients(74%)thatwasevaluated,andopticnervedysfunction,5.8%(6patients).22(21%)patientshadglaucomaassociatedwithGravesophthalmopathythat7(6.7%)ofthemwerenormal-tensionglaucoma.CONCLUSION:EyelidretractionwasthemostcommonclinicalsignofGravesophthalmopathyinourpatients.LargerprospectivestudiesaresuggestedtoevaluateboththeprevalenceandpossibleracialdifferenceinitsclinicalpresentationinIranianpopulation.KEYWORDS:Graves;ophthalmopathy;IranINTRODUCTIONGravesdisease(GD)isaheterogeneousautoimmunedisorderaffectingthethyroid,eyesandskin1.Whilesomedegreeofocularinvolvementmaybedetectedbysensitiveimagingtechniques(magneticresonanceorcomputedtomography)inalmostallpatientswithGravesdisease,clinicallyapparentophthalmopathyoccursinonly30%ofpatientswithGD2.Initssevereexpression,itisadisfiguringandpotentiallysightthreateningdisorder.However,evenmildtomoderatelysevereophthalmopathyprofoundlyinfluencesandimpairsthequalityoflifeofaffectedindividuals3.ThecourseofGravesophthalmopathy(GO)isunpredictableandasuddenworseningofGOcanoccuratanytime.AsthetreatmentofGOisoftenunsatisfactory,thereisaneedtoidentifypossiblepredisposingfactorsandestablishdiagnosticmethodstoidentifyGDpatientsathighriskofdevelopingophthalmopathy4.2TheetiologyofGOisconsideredtobemultifactorial.Sofar,cigarettesmoking,advancingage,malesexandradioiodinetreatmenthavebeenshowntobeassociatedwiththedevelopmentand/orseverityofGO5-9.ThereisalsoanethnicdifferenceintheprevalenceofophthalmopathyinpatientswithGD,withAsianshavingasignificantlylowerriskofdevelopingGOcomparedwithCaucasianslivinginthesameregion(10).Thepresentpaperwillreviewtheclinicalmanifestations,andcomplicationsofGravesophthalmopathyinpatientsthatwerereferredtoourclinicandcomparethisfindingwithotherstudies.MATERIALSANDMETHODSPatientsWeperformed,inaprospectivestudy,physicalandocularexamination,andreviewedmedicalchartofthe103patientswithGravesophtalmopathyamongthepatientsthathadbeenreferredtoFarabiEyeHospital,Tehran,Iran,duringa3-yearinterval(2003through2005).Inclusioncriteriawereasfollows:GravesophthalmopathywasdiagnosedbasedondiagnosticcriteriaofBartleyetal11andinclude;eyelidretraction(uppereyelidpositionatorabovethesuperiorcorneosclerallimbus)occurredtogetherwithobjectiveevidenceofthyroiddysfunctionorabnormalregulation,orexophthalmos(definedasaHertelexophthalmometrymeasurement20mm),oropticnervedysfunction,orextraocularmuscleinvolvement(eitherrestrictivemyopathyorenlargedmusclesasdeterminedbycomputedtomography,magneticresonanceimaging,orultrasonography).Theophthalmicsignscouldbeeitherunilateralorbilateral,andconfoundingcauseshadtobeabsent.Ifthepatientdidnothaveeyelidretraction,thenGravesopththalmopathywasdiagnosedonlyifexophtalmos,opticnerveinvolvement,orrestrictiveextraocularmyopathywasassociatedwiththyroiddysfunctionorabnormalregulationandifnoothercauseorcausesfortheophthalmicfeatureorfeatureswasapparent.MethodsAfterfullocularexamination,includingslitlampexamination,intraocularpressuremeasurement,funduscopy,eyelidexamination,pupillarydefect,exophthalmometry,ocularmovementexamination,findingsforfeaturesrelevanttoGravesophtslmopathywererecordedatthefirstophthalmicexaminations.Informationonthepatientsmedicalstatusincludeddeterminationofthyroidstatus(hyperthyroidism,primaryhypothyroidism,Hashimotosthyroiditis,oreuthyroid),thepresenceofsystemicdisorders,laboratorytestsresultsrelatedtothyroidfunctionatthetimesofinitialdiagnosisofthyroiddysfunctionandophthalmopathyandatsubsequentexaminationswererecorded.Aftercompletingaboveexamination,patientswerereferredforperformingperimetry(HFA;SITAstandard30-2or24-2program)andCT-scan.Opticnervedysfunctionwasdefinedasfollows;decreasedvisualacuity,opticdiscchangeswithdiscedemaoropticatrophy,anafferentpupillarydefect(inasymmetricorunilateralopticnerveinvolvement),enlargedextraocularmusclesattheapexoftheorbitwithcompressionoftheopticnerveshowedonCT-3scanimaging,visualfielddefectespeciallycentralscotomawithoutthetypicalglaucomatousfielddefectespeciallyinthepresenceofhighIOP.Perimetrywasdonewitha