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What is Thyroid Eye Disease?

The thyroid gland is located in the neck. It produces thyroid hormone which helps regulate our metabolism. It may occasionally produce too much thyroid hormone (hyperthyroidism or thyrotoxicosis) or too little (hypothyroidism or myxoedema). Imbalance in either direction can cause eye and vision problems. The precise cause of thyroid eye disease, which may be very variable in its manifestations, remains a mystery. The leading cause of hyperthyroidism, Graves' Disease, represents a basic defect in the autoimmune system, causing production of immunoglobulins (antibodies) which stimulate and attack the thyroid gland. This causes growth of the gland and overproduction of thyroid hormone. Similar antibodies may also attack the tissues in the eye muscles and in the pretibial skin (the skin on the front of the lower leg). Thyroid Eye Disease (TED) is also called Graves' Orbitopathy (GO), dysthyroid eye disease or Thyroid Associated Ophthalmopathy (TAO).
Historical references to what we nowadays know about the thyroid gland arise early in medical history. In 1600 BC the Chinese were using burnt sponge and seaweed for the treatment of goitres (enlarged thyroid glands). Celsus first described a «tumour of the neck» in 15 AD Around this time Pliny referred to epidemics of goitre in the Alps and also mentioned the use of burnt seaweed in their treatment. In 150 AD Galen referred to «spongia usta» (burnt sponge) for the treatment of goitre. He also suggested (incorrectly, as it turns out) that the role of the thyroid was to lubricate the larynx.

In 650 AD Sun Ssu-Mo used a combination of seaweed, dried powdered mollusc shells and chopped up thyroid gland for the treatment of goitre. Ali-ibn-Abbas was the first to discuss surgery as a treatment for goitres in 990 AD. Jurjani's «Treasure of Medicine» in 1110 AD first associated exophthalmus (the protrusion of the eyes we now associate with Graves' Disease) with goitre.

It was not until 1475 that Wang Hei anatomically described the thyroid gland and recommended that the treatment of goitre should be dried thyroid. Paracelsus, some fifty years later, attributed goitre to mineral impurities in the water. Finally, in 1656 Thomas Wharton named the gland the thyroid, meaning shield, as its shape resembled the shields commonly used in ancient Greece.

In 1786 the Irish Caleb Hillier Parry described the «Enlargement of thyroid gland in connection with enlargement or palpitation of the heart» published in the collections from unpublished writings of late Caleb Hillier Parry (Vol 2). London: Underwoods, 1825;111. In 1811, Paris discovered iodine in the burnt ashes of seaweed and the idea that this was the active ingredient in the treatments that were prescribed for goitre developed. Ten years later Prout was the first to recommend iodine in the treatment of goitre. In 1835, another Irishman, Robert James Graves, published his accounts on exophthalmic goitre: «Newly observed affection of thyroid gland in females» in the London Medical Surgery Journal 1835;7:516. Five years later the German physician Carl Adolph von Basedow published his theory about the etiology of exophthalmos, goiter and tachycardia (palpitation of the heart) which became known as the «Triad of Merseburg»:
«Exophthalmos durch Hypertrophie des Cellgewebes in der Augenhöhle». Ord first described myxoedema in 1878. Rehn carried out the first thyroidectomy (removal of the thyroid gland) for exophthalmic goitre in 1880.

Kocher demonstrated that total thyroidectomy caused hypothyroidism and was awarded the Nobel Prize for Medicine in 1909. The idea that the thyroid produced an iodine containing substance was investigated in the last century, and Kendall in 1914 isolated an iodine-containing substance from thyroid tissue. It was not until some 20 years later that Pitt-Rivers and Harrington determined the structure of the first thyroid hormone to be recognised.