R T A Patient With Graves ’ Disease in Whom Presenting Eye Signs Were Associated With Antibodies to the Thyrotropin Receptor and Later Eye Muscle Damage With Antibodies to

e report a 14-year-old female patient with Graves ’ hyperthyroidism and mild eye signs in whom ophthalmo-pathy worsened after several months of treatment with Methimazole and thyroxin. Se-rum antibodies against the eye muscle antigens G2s, flavoprotein (Fp), succinate dehydrogenase (SDH) and flavine adenine Dinucleotide (FAD), and human TSH receptor, were measured retro-spectively in serum taken from the patient over a 3 yr period. High levels of serum antibodies against the TSH receptor [TSH receptor antibody (TRAb)] were detected in the first sample, when mild proptosis, chemosis and diplopia on ex-treme gaze were noted. TRAb levels then de-clined and became negative after 15 months. Twelve months after the initial assessment she developed eye grittiness and excess tearing and, two wk later, antibodies against G2s became positive. Six months later she complained of se-vere upward- gaze double vision and increased proptosis was noted. At that time antibodies against Fp and SDH became positive. This is the first report correlating a patient’s autoantibody levels with clinical symptoms and signs of oph-thalmopathy. Autoimmunity against the TSH re-ceptor may be the initial event in the develop-ment of ophthalmopathy in patients with Graves ‘ hyperthyroidism while antibodies against G2s and Fp are produced later, in asso-ciation with worsening inflammatory changes and eye muscle damage. Despite the close rela-tionship between eye muscle antibodies and clinical eye signs in this patient the antibodies are likely to be secondary to the eye muscle reac-tion, rather than its cause