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Hospital CIMA San José
San José, Costa Rica
(506) 2208 1212
(506) 2208 1340

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Thyroid Eye Disease

Thyroid Eye Disease
The Thyroid gland is located in the front of the neck, adjacent to the trachea (wind pipe). Thyroid gland can become swollen and some times painful during the acute inflammatory period.

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.

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. 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?
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.

Puffiness around the eyes Puffiness around the eyes fixed

Left-hand image shows chronic eyelid swelling and eyelid bags, note the moderate upper eyelid retraction, which gives a stare appearance. Right-hand image show the postoperative results after cosmetic eyelid surgery.

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 of the key features in TED.

When mild, staring may better with time as the eyes settle. But if retraction is severe or has been present a long time the appearance can often improved only after performing eyelid surgery.

Often, however, staring appearance combines with obvious exophthalmos (bulging eye). Your surgeon would suggest to surgically correct bulging eye appearance before performing eyelid surgery.

Orbital decompression surgery if often offered first before any eyelid precedure is performed. Orbital Decompression surgery’s goal is to expand the orbit volume so that swollen orbital contents fit better within it. Such goal can be accomplished by surgically removing one or more bony orbital walls.

A Orbital Decompression Orbital Decompression
B Orbital Decompression Orbital Decompression
C Orbital Decompression Orbital Decompression

Left hand images in rows A, B and C show preoperative pictures, bony (white lines) edges are present. Orbital pressure builds up as tissues swell and muscles engorge. Right hand images in rows A, B and C show postoperative images of three different kinds of orbital decompression techniques. A. Orbital floor removal, B. medial (nose) wall removal and C. Deep lateral wall removal. Bony

Though eyelid surgery often follows orbit decompression surgery, it can be perform as a “stand alone” procedure if staring and eyelid retraction is mild or in cases in which eye globe protrusion is not severe.

TED patients commonly benefit from eyelid procedures concerning upper (and lower) eyelid retraction, as well as cosmetic blepharoplasty.

When a cosmetic blepharoplasty is due, the standard eyelid incisions are performed for upper and lower eyelids, excessive fat is removed or reposition as needed. If significant upper eyelid retraction is present, during the same operative time the upper eyelid tendon can be detached from the tarsus (detaching the tendon releases retraction), allowing eyelid to descent correcting retraction and the stare appearance.

TED patient TED patient

Left-hand image show preoperative image of a TED patient with significant eyelid retraction and its stare appearance. Right-hand image show same patient’s look after successful surgery.

Double vision
Double Vision Double Vision

If this only occurs from time to time and/or only when you look out of the corner of your eyes then it should not interfere with normal activities and does not require treatment, many times it improves with adequate dry eye management. However, if the double vision occurs more frequently then a proper assessment is warrant. Prism lenses can be added to normal eyeglasses to improve the double vision. At a later stage, if the double vision remains, surgery -as for squints in children- can be done to realign the eyes.

Basic eye muscle strabismus surgery technique illustrated. Eye muscle is detached, shorten and reattached, an angle adjustment is achieved each millimeter a muscle shortening is made. Angle correction is the end responsible reason surgeons can repair eye misalignment and double vision.

Deteriorating vision (Optic nerve compression)
If pressure over the optic nerve with in the orbit is suspected urgent expert attention is required as it may mean irreversible visual loss can ensue.

Eye muscle engorgement and subsequent optic nerve crushing is responsible for a particular kind of vision-treating complication known as compressive optic neuropathy.

Immunosuppressive treatment and/or surgery may be needed to relieve pressure over the optic nerve and solve optic nerve compression.

Orbital decompression entitles removing orbital bony walls of the orbit. Orbital decompression surgery has two direct effects:
1. Releases optic nerve compression and alleviates compressive optic neuropathy and, 2. Repositions the eye globe, much improving exophthalmos imposed by TED, substantially ameliorating esthetics and eye surface exposure.

Dr. Piva from the University of Costa Rica and Dr. Chang from University of Southern California jointly developed a unique surgical technique to decompress the orbits of TED patients, obtaining impressive results and helping patients overcome their condition.
Eli L Chang, Alfio P Piva Ophthalmology Vol. 115 Issue 9 Pg. 1613-9 (Sep 2008).

What is immunosuppressive treatment (steroid tablets, radiotherapy)?
When double vision is getting worse or sight is deteriorating, stronger treatment may be used to calm down the immune system (immunosuppressive treatment) and reduce the swelling behind the eyes.

Some specialists use low dose radiotherapy to the orbits. This is often effective and side effects (in experienced hands) are minimal. Currently, standard ‘immunosuppressive treatment’ involves steroid tablets at high dosage. This treatment is effective but can cause swelling of the face, increase in weight, thinning of the bones, sleeplessness, hypertension and diabetes. It is therefore reserved for severe cases and must only be used under close supervision.

Some specialists also use another tablet called Azathioprine along with the steroids so that the same degree of treatment can be achieved with a lower steroid dose. This medication is used in combination with radiotherapy and it is hoped that by treating the disease early the severe complications of thyroid eye disease and the need for surgery can be avoided.

Once the thyroid eye disease reaches the stable uninflamed state, these treatments are no longer needed.

Will the eyes go back to normal?
Occasionally, yes, especially if they were only mildly affected. However, this may take up to 12-24 months. The longer the eye changes have been present, the less likely they will go away, this because the swelling turns to scarring.

Should I see an eye specialist (ophthalmologist)?
Yes. If you have more than minor symptoms this is advisable. The eye specialist will want to see your eyes as soon as possible in case anything can be done to prevent later problems.

Am I likely to lose my sight?
No. It is very rare for the vision to be severely affected. Even when it is, prompt surgery or immunosuppressive treatment can usually improve the situation. Bear in mind that though rare, 8 to 10% of patients with TED can loss their eyesight due to compression over the optic nerve caused by the engorged muscles that choke the nerve.

Medial orbital decompression alleviates optic nerve compression can by removing the nasal (medial) walls of the orbits. Medial orbital wall does give only a modest improvement to the eye bulging problem, but it releases the pressure over the optic nerve in a very effective way.

The changes in my face have affected me badly. Can anything be done about them?
Some of the effects of thyroid eye disease improve with strict medical control and the passage of time. Often, though, the changes persist long term. Many can camouflage these by simple measures such as growing a fringe or wearing tinted or dark glasses, but some patients experience considerable esthetic and psychological difficulties.

Certainly an increasing number of specialists are aware of these problems and are prepared to tackle them, once the disease has reached the stable uninflamed stage. The surgical plan will be tailored to meet the individual’s needs. Though results can be encouraging.

How can the oculoplastic surgeon set the eye back into the orbit?
Orbital decompression surgery began as a surgical procedure performed when sight was at stake due to compressive optic neuropathy. The introduction of safer more accurate surgical techniques allow experienced surgeons to suggest orbital decompression surgery as a way to set the eye back into the orbit, and improve patient’s appearance and only safety.

Orbit Orbit

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