Thyroid Eye Disease

• Pain in the eyes, specifically when looking up, down, or sideways
• Dryness, itching, dry eyes, difficulty wearing contact lenses
• Difficulty in completely closing the eyelids, especially while sleeping
• Puffy, swollen eyelids, inflammation, and swelling of the eye and its surrounding tissues
• Protrusion of one or both eyeballs: Swelling in the orbital tissues causes the eye to be pushed forward or outward–referred to as exophthalmos or proptosis–which can make thyroid eye disease sufferers appear to have a wide-eyed or bulging stare
• Proptosis is present in 70–90% of cases of thyroid eye disease; the swelling that causes proptosis is due to collections of fluid, fat, and inflammatory cells
• Bloodshot appearance to eyes: Redness and swelling of the conjunctiva, the thin layer covering the white part of the eye
• Double vision, called diplopia
• Impaired or decreased vision, often following reduced brightness of colors

Unfortunately, medical treatment of thyroid disorder or Graves’ disease doesn’t usually eliminate any eye problems, which may last one to three years or longer. Although smokers have higher risks of increased severity of the disease, it’s not possible to predict which patients will develop advanced eye disease. This is why sequential exams with your eye care provider are necessary to monitor your vision. Ocular function assessments are recommended to measure your color and peripheral vision when necessary, and there are options like surgery available to treat physical changes caused by TED.

Mild corneal exposure may be treated with different types of eye drop lubricants (tear supplements) to moisturize the eye. Some patients tape their eyes closed when they sleep to prevent further exposure.

Double vision may be initially corrected with the use of prisms attached to glasses, which partially compensates for limited eye movements. Surgery to treat double vision, which involves repositioning the eye muscles, is recommended to repair eye muscle imbalance. This surgery is recommended only after the thyroid eye disease is stabilized and the double vision is measured with sequential measurements.

For patients with loss of peripheral vision and strangulation of the optic nerve, different treatments may be used, including steroid medications, radiation, and/or surgery. Steroid medication decreases the inflammation in the eye muscles and orbital tissue. Steroids are usually given orally, although the intravenous route is sometimes used. The dosage is gradually decreased, and a low dosage is maintained until symptoms improve. Radiation therapy targeted to the tissue behind the eyeball is sometimes used to decrease orbital inflammation. Some physicians use combinations of radiation and steroids.

If the inflammation around the eyes is very severe, powerful drugs may be required to tone down the autoimmune process attacking the eyes. Currently, steroids and other immunosuppressive drugs are showing promise in effectively reducing swelling around the eyes and protecting the eyes from deteriorating vision. However, side effects such as weight gain, thinning of the bones and skin, and diabetes may result if a high dosage is continued for a long period of time. These immunosuppressive drugs are reserved for more severe cases of hyperthyroidism and Graves’ Disease and should be used only under specialist supervision so the side effects can be monitored.

Cases of corneal exposure may need surgery to reposition the eyelids, such as the following.

• Upper eyelid retraction surgery allows the upper eyelids to more adequately cover the eyes
• Lower eyelid retraction surgery helps elevate the position of the lower lid to enhance closure and improve eye dryness
• Lateral tarsorrhaphy is a surgery that involves closing the outer corners of the eyelids so that the eyes do not open too wide
• Ptosis surgery fixes upper eyelid droop and is sometimes needed to raise the upper eyelid so the patient can see better
• Surgical orbital decompression is an important method of relieving severe pressure on the optic nerve, which can threaten vision–the surgery essentially makes room in the eye socket for the swollen and thickened orbital tissue, allowing the bulging eye to relax back into its normal position