Thyoid Eye Disease

Also known as Thyroid Orbitopathy or Graves’ Disease

Thyroid eye disease is an autoimmune inflammatory disorder of uncertain etiology that affects the tissues of the orbit (i.e. eyelids, eye muscles and other soft tissues surrounding the eyes). Patients with this disorder often have an associated thyroid abnormality which may manifest either before, during or after the orbital signs and symptoms. However, a small percentage of patients may have eyelid and orbital manifestations of the disorder without developing a thyroid abnormality.

Disease Characteristics

Thyroid orbitopathy can develop and affect patients with varying degrees of severity. The disease can begin suddenly and progress rapidly over days to weeks or start insidiously and progress gradually over a long period of time. The majority of patients have mild inflammation, the most common signs and symptoms of which are retraction of the upper and/or lower eyelids and bulging of the eyes (also known as proptosis). In cases of moderate inflammation, patients may also have varying degrees of double vision and eyelid swelling as well as visible redness of the lids and eyes. Other common signs and symptoms include, redness, dryness, excessive mucous and tear production, and pain/pressure behind the eyes. A small percentage of patients with thyroid eye disease develop severe inflammation with massive enlargement of the eye muscles which can result in compression of the optic nerve and, and possible, permanent vision loss. In most cases, however, the inflammatory process is self-limited and runs a course lasting 6 months to a couple years before subsiding. After the inflammatory phase of the disease subsides, scarring of eyelid and orbital tissues may result in the persistence of eyelid retraction, proptosis and double vision.

Evaluation and Management

It is important to be evaluated by an ophthalmologist to assess the ophthalmic manifestations of the disease as well as by an endocrinologist to manage concurrent thyroid abnormalities. Patients with mild Thyroid Eye Disease are usually evaluated on a 3 to 4 month interval basis to monitor progression of the disease and managed with measures to reduce ocular symptoms. Patients with moderate to severe Thyroid Eye Disease may require medical or surgical intervention to reduce inflammation or improve vision. Medical treatment starts with more conservative measures of lubricating eye drops, cool compresses, and non-steroidal anti-inflammatory medicine such as Ibuprofen or Naproxen. One of the most important non-invasive, though challenging, interventions in combating disease severity is smoking cessation.   Cigarette smoking has been associated with development of worsening thyroid orbitopathy and increased risk of vision loss, and the importance of  therefore cessation of smoking cannot be overstated.

As disease severity intensifies, IV or oral steroids (prednisone and related medicines) may be required. There are a variety of immune modulating drugs that are now available to mitigate the inflammation, but most are still considered experimental or second line agents.

Once the inflammatory phase of the disease has subsided, surgical rehabilitation can be initiated. Patients with eyelid abnormalities, double-vision or proptosis may be eligible for surgical correction to improve their function and appearance, usually performed in a staged fashion. Orbital decompression [bone and/or fat] will first be considered to allow the eyes to settle back in the eye socket and decrease bulginess. Once that has been achieved, eye muscle surgery will be performed in patients that have bothersome double vision (diplopia). Eyelid retraction repair will then be performed to improve eyelid position to allow better eyelid closure.   As the disease process will cause enlargement of  the eyelid fat and skin, blepharoplasty is often performed to improve cosmesis.

Frequently Asked Questions