Thyroid Eye Disease (Graves’ Ophthalmopathy)

What is Thyroid Eye Disease (Graves' Disease)?

Not all people with thyroid disease have problems with their eyes. It is a common enough problem, however, that many people have expressed a desire to have more information about how their thyroid condition is related to their eye problems and what can be done about it. The eye changes associated with thyroid disease are referred to as Thyroid Related Orbitopathy (TRO). Although TRO is seen in all types of thyroid disorders, it is most common in patients that are or were hyperthyroid. TRO occurs in about 1 out of 20 people that are hyperthyroid. It can also rarely occur in those who are hypothyroid and even when there is an absence of thyroid abnormalities in the body.

Thyroid disease can cause many different eye problems. These include redness and swelling, double vision, decreased vision, eyelid retraction and a protrusion of the eye itself. It is important to realize that if one of these occurs, that it does not mean others will occur. Eye problems will usually occur and frequently change in type or severity for between 6 months and 2 years. Once stabilized, it is unusual for the eyes to start changing again. In some patients the eyes return to normal. Others are left with some type of permanent changes. A great deal can be done to improve these problems, but this may require surgery.

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How Does Thyroid Eye Disease Develop?

Graves’ disease is caused by what is described as an autoimmune process. Autoimmune disease may be understood as a process by which the body sees some part of itself as being foreign and reacts to it much the same way that it would with any bacteria or virus. In the case of Graves’ disease, the body sees the thyroid gland as the foreign object and produces antibodies that attack the thyroid gland. This will often (but not in all cases) cause the thyroid gland to become over active.

Graves’ eye disease is currently believed to be due to a similar autoimmune reaction. However, in the case of Graves’ eye disease, different antibodies attack the muscles associated with eye and eyelid movement. Although the thyroid gland and the eye may be under attack by the same immune system, it is felt that both conditions remain independent of one another. The antibodies that attack the eye can cause inflammation and swelling of the muscles around the eye, which is what can eventually cause protrusion of the eyes, double vision and retraction of the eyelids.

Treating Graves' Disease

An Ophthalmologist specializing in Graves’ Disease has several roles in treating a patient that has eye problems. The first is to help you get through the time when your eyes are changing and provide simple solutions to the irritation, tearing and swelling often associated with Graves’ Disease. Often this involves something as simple as using artificial tears frequently during the day and lubrication ointment at night. Additionally , elevating your head at night, by using several pillows, will often help decrease swelling around the eyes. The second role is to help determine when your eyes have stopped changing so that corrective surgery can commence if necessary. A third role is to help you watch for the rare serious problems associated with Graves’ Disease that need prompt treatment.

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Thyroid Eye Disease Treatment Options

There are many medical and surgical treatment options for Graves’ disease. Which one is right for you depends on the severity of your illness, the type of ocular manifestations of the disease that you might have, and how these affect your daily activities. Your surgeon will discuss with you the treatment options available and will tailor a treatment plan for your needs.

Important symptoms of Thyroid Eye Disease that may require treatment include:

Dry, irritated eyes
- The use of lubricating ointment for the eye (LacriLube, Refresh PM, Tears Renewed, etc.) at night and artificial tears (Tears Natural, HypoTears, Celluvisc, etc.) during the day can provide a great deal of relief.
Double vision
- Often the amount of double vision will change week to week. At times it can disappear completely without treatment. Once the double vision has been stable for at least several months, surgery can be performed to correct it if necessary.
Eyelid retraction
- Surgery involves moving the eyelids into a more normal position. in the upper eyelids this is usually performed by removing or stretching the scarred muscles. In the lower eyelids, a graft is often needed to help push the eyelid upward.
Eye protrusion
- Although less variable than eyelid retraction, the protrusion of the eye can return to normal on its own. After being stable for several months or more, it is sometimes desirable to surgically move the eye into a more normal position. This can be accomplished by removing a portion of the bone below and on the inner side of the eye.
Vision loss
- If your vision decreases significantly bring this to your Thyroid Eye Disease specialist’s attention promptly. Often, medications taken by mouth will return vision to normal. Surgery and/or radiation treatments are occasionally necessary to restore vision.
Eyelid swelling/aging
- Many people with Thyroid Eye Disease have eyes that appear to have prematurely aged. Swelling of the eyelids is one of the reasons for this. If this does not go away on its own it can be surgically removed.

Things to Consider

Preparing for Graves' Disease Treatment

The diagnosis of Graves’ disease is complex. It includes a detailed history and physical examination, laboratory testing, and frequently imaging studies. Your surgeon will discuss with you the necessary tests to reach a diagnosis, the expected course of the illness, and any treatment options available to you.

Potential Risks of Thyroid Eye Disease Treatment

There are many surgical and nonsurgical treatment options for thyroid eye disease. If you require surgery for your condition, there are some risks associated with. Keep in mind that surgery is reserved for patients who would otherwise lose vision from the disease if surgery is not performed. The risks associated with surgery will be thoroughly discussed with you during your preoperative consultation. While no surgeon can ensure that you will never have a complication, rest assured that we are experts in the medical and surgical management of thyroid eye disease. Complications are rare and can he usually be managed to ensure a good outcome.

Recovery From Thyroid Eye Disease Treatment

Following your initial consultation, a detailed plan will be provided to you with the anticipated timeline for improvement. If you do require surgery, and improvement will be noticed immediately after surgery. Your surgeon will discuss with you the anticipated recovery time.

Even after decades of research there are mysteries associated with thyroid disease that we still don’t understand. One of the more puzzling is the relationship between Graves’ Disease and you body’s thyroid disease. A common misconception is that once your medical doctor treats your body’s thyroid problem the eyes would go back to normal. This is often not the case. In some patients the eyes worsen in the months and years after medical treatment despite the body being stabilized. We have seen patients whose eyes first showed sighs of Graves’ Disease 30 years after being stabilized medically. Even though good medical treatment may not prevent or cure Graves’ Disease, it is extremely important to treat the thyroid abnormality and keep your body in proper thyroid balance.