Thyroid Eye Disease

Thyroid Eye Disease

The Thyroid gland is located in the front of the neck, adjacent to the trachea (wind pipe). Thyroid glan Thyroid Eye Disease (TED) is an inflammatory orbital condition that affects the eyelids and orbital contents including the extra ocular muscles and orbital fat. It is almost always associated with Graves disease (GD), but may be seen in association with Hashimoto's thyroiditis, primary hypothyroidism, or thyroid cancer.

First described by Sir Robert Graves in the early 19th century, Graves' disease is one of the most common of all thyroid problems. It is also the leading cause of hyperthyroidism, a condition in which the thyroid gland produces excessive hormones. Once the disorder has been correctly diagnosed, it is quite easy to treat. In some cases, Graves' disease goes into remission or disappears completely after several months or years. Left untreated, however, it can lead to serious complications -- even death. Although the symptoms can cause discomfort, Graves' disease generally has no long-term adverse health consequences if the patient receives prompt and proper medical care

Hormones secreted by the thyroid gland control metabolism, or the speed at which the body converts food into energy. Metabolism is directly linked to the amount of hormones that circulate in the bloodstream. If, for some reason, the thyroid gland secretes an overabundance of these hormones, the body's metabolism goes into high gear, producing the pounding heart, sweating, trembling, and weight loss typically experienced by hyperthyroid people. Normally, the thyroid gets its production orders through another chemical called thyroid-stimulating hormone (TSH), released by the pituitary gland in the brain. But in Graves' disease, a malfunction in the body's immune system releases abnormal antibodies that mimic TSH. Spurred by these false signals to produce, the thyroid's hormone factories work overtime and exceed their normal quota.

1/8

Thyroid Eye Disease

Only a small percentage of all Graves' patients will experience a condition known as Thyroid Eye Disease (TED). Even among those who do, the severity of their bout with Graves' has no bearing on the seriousness of the eye problem or how far the eyeballs protrude. In fact, it isn't clear whether such eye complications stem from Graves' disease itself or from a totally separate, yet closely linked, disorder.

TED occurs in about 50% of patients who currently have, or have had, Graves' hyperthyroidism. About 10% of patients, however, never develop thyroid malfunction.

The ocular manifestations of Thyroid Eye Disease (TED) include soft tissue inflammation, eyelid swelling, eyelid retraction, eyelid lag -a delay in the downward excursion of the upper eyelid in down gaze ( see video )-, corneal exposure, and optic nerve compression due to swollen eye muscles that can put tremendous pressure on the optic nerve. Double vision due to eye squinting can also develop. Finally, exophthalmos (bulging eyes), the most distinctive sign of TED frequently causes cosmetic disability affecting quality of life.

Eyelid retraction can affect upper (red arrows) and lower (green arrows) eyelids. Eyelid retraction is responsible for patients’ stare appearance. Eyelid swelling causes a puffy appearance of both upper and lower eyelids. Another key feature of TED patients is Eye-bulging appearance (exophthalmos).

Thyroid Eye Disease patients, however, appear to suffer silently trying to overcome facial disfigurement, visual disturbances, dry eye syndrome, double vision and eye pain.

This particular unkind health problem causes a variety of physical and psychological problems.

2/8

Thyroid Eye Disease

Causes patients to avoid social contact, relationships breakdown, and depression.

Surgery is fortunately a treatment option once the underlying medical condition has been stable. Surgery protects vision, rehabilitates eye movement deficiency and eye squinting, and improves eyelid esthetics.

In general, surgical rehabilitation entitles an orderly stepwise process in which eye globe protrusion (bulging eyes) is treated first, strabismus and double vision second and eyelid esthetics for last.The process, though, must always be customized to particular patient's needs.

A few frequently asked questions What causes TED? Will the treatment for the thyroid gland make the eyes better? Can thyroid eye disease be prevented? Will my eyes get worse? Irritation and redness of the eyes Puffiness around the eyes Stare eyes (eyelid retraction) and bulging eye appearance (exophthalmos) Double vision What is immunosuppressive treatment (steroid tablets, radiotherapy)? Deteriorating vision (Optic nerve compression) Will the eyes go back to normal? Should I see an eye specialist (ophthalmologist)? Am I likely to lose my sight? The changes in my face have affected me badly. Can anything be done about them? How can the oculoplastic surgeon set the eye back into the orbit?

What causes TED? Over activity of the thyroid gland is usually caused by an "autoimmune condition". Cells, which normally protect the body from infection, develop a "fault" and begin to recognize the thyroid gland and orbit tissues as foreign a material and attack them. This stimulates the thyroid gland to produce extra thyroid hormones, as well as all previously described signs and symptoms. Thyroid eye disease does appear to be more common in smokers.

Will the treatment for the thyroid gland make the eyes better?

3/8

Thyroid Eye Disease

Generally no. Treatment of thyroid over activity with tablets, iodine-131 or surgery rarely benefits the eye problem. Since the eye and thyroid gland problems, although connected in some way, run their own separate courses, worsening of the eyes after thyroid treatment is often a coincidence rather than a direct effect of the thyroid treatment. Just the same way thyroid gland treatment does not improve the eye condition.

Can thyroid eye disease be prevented? Yes, to some extent. Giving up smoking and careful checks of thyroid blood level to avoid under activity may help prevent the eye problems getting worse although they are not the full answer. All too often the eye condition runs its own path.

Will my eyes get worse? For most patients, thyroid eye disease only causes irritation of the eyes, a little starriness (eyelid retraction) and some puffiness around the eyes. This carries on usually for a few months, occasionally one to two years, and then settles down by itself. In about 1 in 10 people the eyes get worse. This usually happens within a few months of the problem starting, so that if the eyes have been the same for more than six months it is unusual for them to get worse.

Irritation and redness of the eyes Simple eye drops such as ‘artificial tears' ('viscotears' or ‘refresh tears eye drops’) will usually give relief. These drops are harmless and can be applied as often as required, even as much as hourly. For longer effect Ointments or gels may be used during the day or night.

Puffiness around the eyes This is more difficult to treat. The puffiness is unsightly but not dangerous. It is worse in the morning after lying flat and may be helped by using an extra one or two pillows or bolster to raise your head at night, raising the head of the bed on blocks or using a diuretic (water tablet) at night-time. Usually the swelling does improve after several months as the eyes settle. Eyelid esthetic surgery can be used to improve the appearance in many cases.

4/8

Thyroid Eye Disease

Left-hand retraction, after cosmetic image which eyelid shows gives surgery. achronic stare appearance. eyelid swelling Right-hand and eyelid image bags, show notethe thepostoperative moderate upper results eyelid Stare eyes (eyelid retraction) and bulging eye appearance (exophtalmos)

Image shows asymmetric eyelid retraction and unilateral stare. Stare appearance, caused by eyelid retraction, is one ofone the key in When been present mild, staring ais long may time better the appearance with time ascan the often eyes improved settle. But only if features retraction after performing isTED. severe eyelid or has Often, surgeon surgery. however, would suggest staring to appearance surgically correct combines bulging with obvious eye appearance exophthalmos before (bulging performing eye). eyelid Your Orbital decompression surgery ifby often offered first before any eyelid precedure iswalls. performed. bital Decompression Such surgery’s goal goal can be to accomplished expand the orbit surgically volume soremoving that swollen orbital or more contents bony orbital fit better within it. Or A

5/8

Thyroid Eye Disease

B

C

6/8

Thyroid Eye Disease

Left present. rows techniques. removal. hand A, B Orbital Bony images and C Orbital pressure show in rows floor postoperative builds A,the removal, B and up C as B. images show tissues medial preoperative ofswell (nose) three and different wall muscles pictures, removal kinds engorge. bony and ofwhich orbital (white C. Deep Right decompression lines) lateral hand edges images arein Though alone” is notlower severe. eyelid surgery ifblepharoplasty staring often and follows eyelid orbit retraction decompression is mild or surgery, in cases itin can beperformed perform eye globe as protrusion awall “stand TED retraction, patients asA. commonly well as benefit from eyelid procedures concerning upper (and lower) eyelid cosmetic blepharoplasty. When and retraction from the aprocedure cosmetic tarsus is and eyelids, present, the (detaching stare excessive during appearance. the fattendon same isisremoved due, operative releases the or standard reposition retraction), time the eyelid upper as allowing needed. incisions eyelid eyelid Iftendon are significant to descent can be upper for detached correcting upper eyelid

Left-hand its stare vision appearance. image showRight-hand preoperative image image show of asame TED patient’s patient with looksignificant after successful eyelid retraction surgery. and Double

If this then improves frequently eyeglasses -as for itonly should squints with then occurs to not adequate improve ina childrenproper interfere from the time dry assessment can with double to eye time be normal management. done vision. and/or isactivities to warrant. At realign only a later However, when and Prism the stage, does eyes. you lenses iflook ifnot the thecan require out double double be of the added treatment, vision vision corner to occurs remains, normal ofmany your more surgery times eyes it

7/8

Thyroid Eye Disease

Basic and Angle double reattached, eye correction vision. muscle an is strabismus the angle end adjustment responsible surgery istechnique reason achieved surgeons illustrated. each millimeter can Eye repair muscle a muscle eye is misalignment detached, shortening shorten and is made. Deteriorating vision (Optic nerve compression) as If pressure itReleases may mean over irreversible the optic nerve visual with loss in can the ensue. orbit is suspected urgent expert attention isbe required kind Eye muscle of vision-treating engorgement complication and subsequent as optic compressive nerve crushing optic is neuropathy. responsible for a particular Immunosuppressive nerve and solve optic treatment nerve compression. and/or surgery may becompressive needed to relieve pressure over the optic Orbital surgery decompression has two direct effects: entitles removing orbital bony walls of the orbit. Orbital decompression Repositions ameliorating 1. the esthetics optic eye nerve and compression eye much surface improving and exposure. alleviates exophthalmos imposed optic by TED, neuropathy substantially and, 2. Dr. jointly obtaining Piva developed from impressive the a University unique results surgical of and Costa helping technique Rica patients and to Dr. decompress overcome Chang from their the University orbits condition. of of TED Southern patients, California Eli L Chang, Alfio Pglobe, Piva Ophthalmology Vol. 115 Issue 9compression Pg. 1613-9 (Sep 2008). What is immunosuppressive treatment (steroid tablets, radiotherapy)? calm the When eyes. double the vision immune is getting system worse (immunosuppressive or sight is deteriorating, treatment) and treatment the swelling may behind used to Some (in involves face, therefore increase specialists steroid reserved in hands) tablets weight, use for low severe at are thinning dose high minimal. cases dosage. radiotherapy of the and Currently, This bones, must treatment to only standard the sleeplessness, orbits. be used is ‘immunosuppressive effective This under is hypertension often but close can effective supervision. cause and treatment’ and diabetes. swelling side effects of It the is in same combination complications degree with of of treatment thyroid radiotherapy also use eye can another disease and be achieved tablet itknown is and hoped called the with need that Azathioprine a by for treating surgery steroid along the can dose. disease be with avoided. This the early medication steroids the severe so is that the Once longer needed. thyroid disease reaches the stable uninflamed state, these treatments are no Will the go back to normal? 12-24 this Occasionally, because months. the yes, The swelling especially longer turns the ifeye to they scarring. changes were only have mildly been affected. present, However, the less likely this may they take will go up away, to Should Ieyes see an eye specialist (ophthalmologist)? see Yes. Ifthe you eyes have as more soon as than possible minor symptoms in case anything this islower advisable. can be done The to eye specialist later problems. will want to Am Iyour likely to lose my sight? immunosuppressive 8 caused No. toexperienced 10% Itdown is by very of the patients rare engorged for with treatment the muscles TED vision can can to that be loss usually severely choke their improve eyesight the affected. nerve. the due situation. Even to when Bear itprevent is, in prompt mind over that the surgery optic though nerve or rare, Medial (medial) bulging orbital problem, walls decompression of the but orbits. itthe releases Medial alleviates the orbital pressure optic wall over nerve does the give compression optic only nerve astronger modest can in areduce by very improvement removing effective the way. to nasal the eye The changes in my face have affected me badly. Can anything be done about them? Some of the effects of thyroid eye disease passage simple experience measures of considerable time. Often, such as though, esthetic growing the and a changes fringe psychological or persist improve wearing difficulties. long with tinted term. strict or dark Many medical glasses, can control camouflage but and some the these patients by Certainly tackle be tailored them, an to increasing once meet the the disease individual’s number has of specialists needs. reached the are stable aware results uninflamed of can these be problems encouraging. stage. The and surgical are prepared plan will to How can the oculoplastic surgeon set eye back into the orbit? stake techniques set Orbital the due eye decompression to allow back compressive into experienced surgery orbit, optic surgeons and neuropathy. began improve as tothe aThough suggest surgical patient’s The introduction orbital procedure appearance decompression of performed safer and more only when surgery safety. accurate sight as surgical awas way at to

Orbitalorbital bony swollen appearance decompression due walls to in thyroid TED. encase Increasing eye surgery engorged disease entails orbital patients. orbital the volume removal soft by tissues, removing of one which orbony more have walls orbital become improves walls. inflamed Inthe TED eye-bulging and patients

8/8