Lid retraction, causing a staring appearance, can occur in any form of thyrotoxicosis and is the result of sympathetic overactivity. However, GD is associated with specific eye signs that comprise TAO. This condition may occur in the absence of GD in 10 % of patients. Most of these individuals have autoimmune hypothyroidism or thyroid antibodies. The onset of TAO occurs within the year before or after the diagnosis of thyrotoxicosis in 75 % of patients but can sometimes precede or follow thyrotoxicosis by several years, accounting for some cases of euthyroid TED. Many patients with GD have little clinical evidence of TED. However, the enlarged extraocular muscles typical of the disease can be detected in almost all patients when investigated by ultrasound or computed tomography (CT) imaging of the orbits [20]. Unilateral signs are found in up to 10 % of patients.

The earliest manifestations of TED are a sensation of grittiness, eye discomfort, and excess tearing. About a third of patients have proptosis, best detected by visualization of the sclera between the lower border of the iris and the lower eyelid, with the eyes in the primary position. Proptosis can be measured using an exophthalmometer. In severe cases, proptosis may cause corneal exposure and damage, especially if the lids fail to close during sleep. Periorbital edema, scleral injection, and chemosis are also frequent. In 5–10 % of patients, the muscle swelling is so severe that diplopia results, typically but not exclusively when the patient looks up and laterally. Muscle swelling may also cause compression of the optic nerve at the apex of the orbit, leading to optic nerve swelling, visual field defects, and if left untreated, permanent loss of vision.

Clinical features of TED vary from a mild grittiness of the eyes to severe diplopia, disfiguring proptosis, and loss of vision. There is a natural tendency towards spontaneous improvement: the spontaneous course depicts an active phase, which slowly abates after which an inactive phase ensues [21]. The most common signs of TED are eyelid retraction (90 %), soft tissue involvement (80 %), proptosis (50–60 %), dry eye syndrome (50 %), motility disorders (40 %), optic neuropathy (3–5 %), and superior limbic keratitis (2 %) [17]. The autoimmune process leads to an accumulation of collagen and hydrophilic glycosaminoglycans within the orbit. Inflammatory changes of the eyelids cause visible edema and erythema. If extraocular muscles are affected motility disorders may occur. Patients with motility disturbances, severe and active disease have a severely impaired health-related quality of life [22].

Many scoring systems have been used to gauge the extent and severity of the orbital changes in GD. The NOSPECS scheme [23, 24] includes six classes of eye changes. TED is classified as severe if corneal involvement, severe proptosis, constant diplopia, or optic neuropathy is present [25]. Evaluating the activity of TED is required to choose the most effective and stage adjusted therapy. TED is active when inflammatory signs such as redness and swelling predominate and there are progressive changes in objective measurements such as exophthalmos, eyelid position, and motility. Several groups have tried to develop methods to assess activity of TED. These include purely clinical assessments (clinical activity score, CAS [26]), laboratory measurements (cytokines, glycosaminoglycan excretion, TSHR stimulating autoantibodies or TSAb [27]), and imaging techniques [20]. Clinical evaluation of the CAS together with measurement of TSAb serum levels is helpful to document disease activity.

General ophthalmic assessment should include examination of anterior and posterior eye segment, applanation tonometry, Hertel exophthalmometry, and motility tests. Additionally, the observer classifies whether there is optic disc edema or disc pallor and records whether choroidal folds are present. In addition to fundus exam, relative afferent pupillary defects, visual field defects, color vision abnormalities, visually evoked potentials, and visual acuity are tested to determine whether optic neuropathy is present. Cigarette smoking can profoundly influence the occurrence and the course of TED [28], and also impairs its response to conservative treatment [29]. Accordingly, patients should be strongly urged to stop smoking, as refraining from smoking favorably influences the course of TED. Also, emotional distress and stressful life events are risk factors for TED and should therefore be minimized [30, 31].

In GD, below-normal to suppressed levels of baseline serum TSH, normal to elevated serum levels of T4, elevated serum levels of T3 and of TSHR autoantibodies, as well as a diffusely enlarged, heterogeneous, hypervascular thyroid gland (increased Doppler flow in the ultrasound evaluation of the neck) confirm diagnosis of GD [1, 35, 36]. In 2–5 % of patients and more commonly in areas of borderline iodine intake, only T3 is increased (T3 toxicosis). The converse state of T4 toxicosis, with elevated total and free T4 and normal T3 levels, is occasionally seen when hyperthyroidism is induced by excess iodine, providing surplus substrate for thyroid hormone synthesis. Associated abnormalities that may cause diagnostic confusion in thyrotoxicosis include elevation of bilirubin, liver enzymes, and ferritin. Microcytic anemia and thrombocytopenia occur less often.

Currently, two different methods of assessing autoantibodies directed against the TSHR are used. The TSHR binding inhibitory immunoglobulin (TBII) assay detects antibodies that inhibit the binding of TSH to purified or recombinant TSHR. It thus measures both thyroid stimulating (TSAb) and thyroid blocking (TBAb) antibodies that target the receptor. During the entire pregnancy of patients with GD, circulating anti-TSHR-autoantibodies can pass to the baby and cause either neonatal autoimmune thyrotoxicosis (functionally stimulating autoantibodies) or hypothyroidism (blocking autoantibodies). The second method is a cell-based reporter bioassay that can distinguish between TSHR-stimulating, -neutral (binding), and -blocking autoantibodies through their effect on cyclic adenosine monophosphate (cAMP) production in a cell line stably transfected with the receptor [27, 37–39]. The levels of TSAb closely correlate with activity and severity of TED [33], and in approximately 50 % of the cases also are of prognostic value regarding the course of the disease [40].

The commercially available TBII tests that are used to measure the binding of sera to TSHR display high sensitivity and specificity for TSHR autoantibodies, but unfortunately do not measure the functional activity of immunoglobulins and do not distinguish between stimulatory, blocking, and neutral activity [35]. In contrast, anti-TSHR bioassays offer the following advantages: (1) the biological activity of specific immunoglobulins is directly assessed on a fully functional TSHR holoreceptor expressed on intact live cells, a platform that is easily adaptable and tailored to detect antibodies of specific function; (2) the bioassay measures the specific function of autoantibody that highly correlates with Graves’ activity; (3) the monitoring of TSAb levels and TSAb titers add another dimension to the assessment of TED severity in individual patients.

Diagnosis of GD is straightforward in a patient with biochemically confirmed thyrotoxicosis, diffuse goiter on palpation, associated TED, positive TSHR antibodies, and often a personal or family history of autoimmune disorders [1, 2]. For patients with thyrotoxicosis who lack these features, the most reliable diagnostic methods are ultrasound evaluation [36] of the neck looking for a hypervascular gland and/or a radionuclide scan of the thyroid, which will distinguish the diffuse, high uptake of Graves’ disease from nodular thyroid disease, destructive thyroiditis, ectopic thyroid tissue, and factitious thyrotoxicosis. In secondary hyperthyroidism due to a TSH-secreting pituitary tumor, there is also a diffuse goiter. The presence of a non-suppressed TSH level and the finding of a pituitary tumor on CT or magnetic resonance imaging (MRI) scan readily identify such patients [20]. While MRI is helpful in the differential diagnosis of proptosis, though computed tomography (CT) of the orbits remains the mainstay of radiographic imaging in the evaluation of patients with known TED for assessment of orbital tissue expansion and bony anatomy in preparation for surgical intervention [41]. Clinical features of thyrotoxicosis can mimic certain aspects of other disorders including panic attacks, mania, pheochromocytoma, and the weight loss associated with malignancy. The diagnosis of thyrotoxicosis can be easily excluded if the TSH level is normal. A normal TSH also excludes GD as a cause of diffuse goiter.

Clinical features generally worsen without treatment; mortality was 10–30 % before the introduction of satisfactory therapy. Some patients with mild GD experience spontaneous relapses and remissions. Rarely, there may be fluctuation between hypo- and hyperthyroidism due to changes in the functional activity of TSHR antibodies. About 15 % of patients who enter remission after conservative treatment develop hypothyroidism 10–15 years later as a result of the destructive autoimmune process. The clinical course of TED does not follow that of the thyroid disease. TED typically worsens over the initial 3–6 months, followed by a plateau phase over the next 12–18 months, with spontaneous improvement, particularly in the soft tissue changes. However, the course is more fulminant in up to 5 % of patients, requiring intervention in the acute phase if there is optic nerve compression or corneal ulceration. Diplopia may appear late in the disease due to fibrosis of the extraocular muscles. Radioiodine (RAI) treatment for hyperthyroidism worsens the eye disease [42] in approximately 15–20 % of patients (foremost smokers). Antithyroid drugs and/or surgery have no adverse effects on the clinical course of TED [43]. Dermopathy, when it occurs, usually appears 1–2 years after the development of Graves’ hyperthyroidism; it may improve spontaneously.

The hyperthyroidism of GD is treated by reducing thyroid hormone synthesis, using antithyroid drugs (anti-TDs), or by reducing the amount of thyroid tissue with RAI treatment or near-total thyroidectomy [44–46]. Anti-TDs are the predominant therapy in many centers in Europe and Japan, whereas RAI is more often the first line of treatment in North America [47]. These differences reflect the fact that no single approach is optimal and that patients may require multiple treatments to achieve remission. The main anti-TDs are the thionamides, such as propylthiouracil (PTU), carbimazole, and the active metabolite of the latter, methimazole (MZ). Carbimazole is not an active substance; it has to be decarboxylated to MZ in the liver. Thionamides are the most widely used anti-TD [48]. They inhibit the coupling of iodothyronines and hence the biosynthesis of thyroid hormones. All inhibit the function of thyro-peroxidase, reducing oxidation and organification of iodide (Table 1.3). Anti-TDs are indicated as a first-line treatment of GD, particularly in younger subjects, and for short-term treatment of GD before RAI therapy or thyroidectomy [49]. Anti-TDs also reduce thyroid antibody levels, and they appear to enhance rates of remission. PTU inhibits deiodination of T4:T3 [50]. However, this effect is of minor benefit, except in the most severe thyrotoxicosis, and is offset by the much shorter half-life of this drug compared to MZ (Table 1.4). There are many variations of anti-TD regimens. The initial dose of MZ is usually 10–15 mg every 12 h, but once-daily dosing is possible after euthyroidism is restored. PTU is given at a dose of 100–200 mg every 6–8 h, and divided doses are usually given throughout the course. Lower doses of each drug may suffice in areas of low iodine intake. The starting dose of anti-TD drugs can be gradually reduced (titration regimen) as thyrotoxicosis improves. Alternatively, high doses may be given combined with levothyroxine supplementation (block and replace regimen) to avoid drug-induced hypothyroidism. Initial reports suggesting superior remission rates with the block-replace regimen have not been reproduced in several other trials [44, 47]. The titration regimen is often preferred to minimize the dose of anti-TD and provide an index of treatment response. Thyroid function tests and clinical manifestations are reviewed 3–4 weeks after starting treatment, and the dose is titrated based on free T4 levels. Most patients do not achieve euthyroidism until 6–8 weeks after treatment is initiated. TSH levels often remain suppressed for several months and therefore do not provide a sensitive index of treatment response. The usual daily maintenance doses of anti-TD in the titration regimen are 2.5–10 mg of MZ and 50–100 mg of PTU.