Thyroid Eye Disease

What is Thyroid Eye Disease?

Thyroid Eye Disease (TED) or Graves’ Orbitopathy (GO) is an autoimmune condition of the eye socket, affecting the muscles and fatty tissue behind the eye, causing them to become swollen, red and inflamed, while sometimes altering their appearance and making them bulge, or scarring the muscles that move the eye, causing double vision. In rare cases, TED can lead to blindness caused by optic nerve compromise at the back of the eye or from corneal exposure and infection at the front of the eyes. Whilst it is normally associated with a history of thyroid disease (particularly hyperthyroidism), this is not always the case. In its mild form, Thyroid Eye Disease is frequently misdiagnosed as a variety of other conditions and commonly requires specialist expertise to give an accurate diagnosis.
This condition has two main phases: an active phase and a quiescent, or 'burn out' phase. Patients with active Thyroid Eye Disease will need to see an oculoplastic surgeon regularly who will often use a variety of treatments to reduce the active inflammation and limit the development of the disease.

In the burnt out phase, patients often have to contend with significant disfigurement with an altered facial appearance. The goals of treatment in this phase are to restore the pre-illness facial appearance and this will often include several different types of surgery to the eye socket, eyelids, and sometimes the muscles that move the eye.

What are the symptoms of TED?

The main symptoms are caused by dry eye; watering, grittiness and discomfort/soreness. Dry eye occurs when the lacrimal gland, which is there to produce tears, is affected by Thyroid Eye Disease. Common symptoms of TED include:

  • Bulging eyes (giving a ‘staring’ look)
  • Pain and discomfort
  • Feeling of eye grittiness
  • Swelling in upper eyelids
  • Eye bags
  • Redness of eyelids
  • Sensitivity to light
  • Blurred or double vision
  • Dry or watery eyes
  • Finding it hard to move the eyes
  • Sight loss
Thyroid Eye Disease is often mistaken for other common eye conditions, such as conjunctivitis, allergies and hay fever, leading to misdiagnosis and therefore, lack of relief from symptoms. In such cases, a patient may be referred to a specialist eye doctor for further examination. .

What causes Thyroid Eye Disease?

The disease mostly affects young or middle-aged women and the most common cause is Graves’ disease, an autoimmune disease affecting the thyroid. Graves’ disease is the most common cause of hyperthyroidism (overactive thyroid). Around one-quarter of people who have Graves’ disease will develop TED. This can occur before, during or after they are diagnosed with a thyroid condition.

People with thyroid conditions should monitor and control their hormone levels, ensuring regular thyroid blood tests are undertaken and medication is used properly.

In the majority of people, TED will be mild, and this is particularly the case if there are no present symptoms of TED when the patient is diagnosed with Graves’ disease and where they are a non-smoker. In such people, the chance of developing TED is less than 1 in 10.

Thyroid Eye Disease and smoking

Smoking is certainly linked to Thyroid Eye Disease, with the chances of developing it doubled compared to non-smokers. Heavy smokers are eight times more likely to develop the condition than non-smokers.

Smoking can also make the disease more severe which means that people are less likely to respond positively to treatment programmes. As such, giving up smoking is essential for those with the condition – speak to your GP for help and advice on quitting.

How is TED diagnosed?

People with thyroid problems, particularly those with overactive thyroids should be made aware of the increased possibility of developing the condition and their GP should explain the symptoms to look out for. However, TED can occur at any time after or before a thyroid problem is detected, which is why many people are misdiagnosed.

The majority of patients with thyroid conditions will only go on to develop mild TED symptoms. Your GP should refer you to a specialist ophthalmologist (eye doctor), who may work in partnership with an endocrinologist (hormone specialist) to help manage the condition and live a happier life. The ophthalmologist can diagnose thyroid eye disease by carrying out an eye examination or scans if necessary.

How is Thyroid Eye Disease treated?

Artificial tear drops can be prescribed to help people with mild forms of TED. These can improve dry eye symptoms such as gritty, watery eyes and discomfort under bright lights. Taking Selenium supplements twice a day for 6 months can also help to improve mild symptoms. However, in more severe cases of thyroid eye disease your GP may refer you to an Ophthalmologist; an eye condition specialist who can help determine the best treatment option.

The condition has two main phases: an ‘active’ phase and an ‘inactive’, or 'burn out' phase. The active stage is when the period of inflammation and swelling takes place, usually lasting between six months and two years. The ‘burn out’ stage will be when the inflammation calms down and is, therefore ‘inactive’. The longer the active stage lasts, the less likely it is that your eye will return to its normal appearance and other symptoms like double vision can become a long-term issue.

Patients with active Thyroid Eye Disease will need to see an oculoplastic surgeon regularly, who will use a variety of treatments to reduce the active inflammation and limit the progression of the disease while protecting the eye. This usually involves treating dry eye or double vision.

Surgical Treatment

In the burn out phase, patients often have to contend with significant disfigurement, with an altered facial appearance and double vision. The goal of treatment in this phase is to restore the pre-illness facial appearance and provide better eye protection. This will often include several different types of surgery to the eye socket, eyelids, and sometimes the muscles that move the eye.

Restorative cosmetic surgery is often performed in a number of stages and you may require several procedures. First, orbital decompression surgery takes place to reduce the amount of proptosis (bulging, staring eyes) by pushing the eyes back into their sockets to improve appearance. After this, surgery for double vision may take place to improve the eyes’ alignment if persistent double vision is a problem. Finally, eyelid surgery may also be necessary for lid retraction, in order to correct the upper and lower eyelid positions, allowing them to open and close properly and protect the eyes as they should. If eye bags are present following TED, these can also be surgically removed.

Eyelid surgery will also usually require blepharoplasty or Blepharoplasty PLUS procedures to really improve appearance. These several thyroid eye disease surgeries will normally be carried out over a period of 18 months to two years and only once the active stage has finished.

Thyroid Eye Disease can have a dramatic effect on quality of life and can seriously affect your day-to-day happiness. The constant irritation and changed appearance of the eyes affects people both physically and mentally. Our research has demonstrated that surgery helps improve quality of life and is a valuable treatment option for many TED sufferers.