WHAT IS THYROID EYE DISEASE?

Thyroid Eye Disease (TED) or Graves’ Orbitopathy (GO) is an autoimmune inflammatory condition of the eye socket. It affects the muscles and fatty tissue behind the eye, causing them to become swollen, red and inflamed. This can affect patients in many ways. It often makes the eyes feel swollen and gritty, but in more severe cases can affect the vision and cause facial disfigurement.

WHO GETS THYROID EYE DISEASE?

Thyroid eye disease most commonly affects people with hyperthyroidism in association with Graves disease, though it can occur in other contexts. It is not common and has an incidence of around 19 per 10000. All age groups may be affected though it most frequently occurs in the working age population, and women are more commonly affected than men. Whilst it is normally associated with thyroid problems, (particularly hyperthyroidism associated with Graves), this is not always the case. Women are more commonly affected, and the disease can also affect patients during pregnancy.

How serious is thyroid eye disease?

In its milder forms, it causes ocular irritation and swelling around the eyes. In this situation it is frequently misdiagnosed as other conditions, such as allergic eye disease, hayfever or dry eye and therefore commonly requires specialist expertise to give an accurate diagnosis. In its more severe forms, it can cause “bulging” of the eyes, marked ocular discomfort, double vision and alterations in appearance. In its most severe forms, it can threaten the vision or even cause blindness due to compression of the optic nerve behind the eye, or due to an inability to close the eyes, leading to corneal exposure.
close up of an eye

WHAT ARE THE SYMPTOMS OF THYROID EYE DISEASE?


In the milder forms of thyroid eye disease, these are related to dry eye. If the condition is more severe, symptoms re related to increased inflammation around the eye, resulting in bulging eyes are double vision.

  • A feeling of eye grittiness
  • Swelling in upper eyelids
  • Eye bags
  • Redness of eyelids
  • Sensitivity to light
  • Blurred or double vision
  • Dry or watery eyes
  • Bulging eyes (giving a ‘staring’ look)
  • Pain and discomfort
  • Finding it hard to move the eyes
  • Sight loss

HOW IS TED DIAGNOSED?

For most patients, thyroid eye disease is mild. An awareness of the condition is therefore essential. People with thyroid problems, particularly those with overactive thyroids should be aware of the increased possibility of developing the condition. Their GP should explain the symptoms to look out for. However, TED can occur after or before a thyroid problem is detected, which is why many people are misdiagnosed.Most 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 a comprehensive eye examination, arranging specliased blood tests and requesting scans of the orbit, such as a CT scan or MRI if necessary.

HOW LONG DOES IT LAST AND WHAT CAN I DO ABOUT IT?

Thyroid eye disease classically follows a typical course of an “active” phase, lasting around 18 months (although this may range from about. 6 months to 2 years). followed by an “inactive” phase.

WHAT TREATMENTS ARE AVAILABLE DURING THE “ACTIVE” PHASE?

Thyroid eye disease classically follows a typical course of an “active” phase, lasting around 18 months (although this may range from about. 6 months to 2 years). followed by an “inactive” phase.

WHAT ABOUT DURING THE “INACTIVE” PHASE?

Once thyroid eye disease has “burnt out”, patients may have to content with changes in their appearance. These may be mild, or in some cases, may result in significant disfigurement and double vision. The treatment of this is primarily surgical and there are several different types of surgery which can be employed to restore cosmesis, to return to the pre-illness facial appearance. Restorative cosmetic surgery is often performed in several stages and you may require several procedures. First, orbital decompression surgery reduces 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 improve the eyes’ alignment if persistent double vision is a problem. Finally, eyelid surgery may also be necessary for lid retraction, 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 improve appearance. These several thyroid eye disease surgeries will normally be carried out over 18 months to two years and only once the active stage has finished.Thyroid Eye Disease (or Graves Eye Disease) can dramatically affect the quality of life and can seriously affect your day-to-day happiness. The constant irritation and changed appearance of the eyes affect 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.

WHAT IS THE RELEVANCE OF SMOKING?

Smoking is strongly 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.

OUR DEDICATED TEAM APPROACH TO YOUR TREATMENT

Thyroid eye disease can be complicated and can affect different people in different ways. Many factors require detailed consideration, including thyroid hormone control, an accurate ophthalmic assessment and diagnosis, review of orbital imaging, the delivery and management of medication and immunosuppression in some patients and the selection of patients for surgery prior to the delivery of surgical therapy. At The Ezra Clinic, we offer a dedicated multidisciplinary service, where specialists from different areas will come together to discuss and review your management in order to deliver the best possible care. Our team is led by Dr Damato, a specialist in the medical treatment of TED, often in collaboration with an endocrinologist, a radiologist and other oculoplastic surgeons from the Clinic.  We meet regularly to review your results, scans and photos and plan ongoing management as part of a multidisciplinary team. This unique team based approach ensures that you are in the best possible hands and have the best possible treatment.

YOUR NEW PATIENT APPOINTMENT

The first appointment is critical step in determining how to plan your care. All new TED patients are seen by Dr. Damato for an in-depth initial assessment. A CT scan of the eye sockets, along with a range of blood tests are usually carried out and your case will be discussed by the TED Multidisciplinary team.  Further treatment will depend very much on which of the two main phases of the disease you may be in:

  • If  you are in the “Active Phase”, this means that the disease is progressing actively. The eyes are often painful and red. You may also feel that things are getting worse every few days.  The Active phase may respond to immunosuppression such as steroids or newer biologics. At the Ezra Clinic, we are able to offer a wide range of treatments for the Active Phase.
  • The “Burned out”, or “inactive phase” describes the disease when it becomes stable. The goal is to reverse the changes that have occurred. This is commonly performed surgically,  and may require a range of treatments such as orbital decompression, eyelid lowering, blepharoplasty, or sometimes all of these surgeries. The image opposite demonstrates the types of outcomes we can achieve in arresting the progress of the disease medically and providing surgery to reverse any disfigurement.

BEFORE AND AFTER

This lady presented with severe thyroid eye disease. She demonstrates typical changes including lid retraction,  bulging eyes and eyelid bags. She was treated initially with an orbital decompression to restore the position of the eyes.

This was followed by upper and lower lid blepharoplasty with midface lift to restore the cheek volume and smooth interface with the eyelid. The results were transformational as seen in the before and after eyelid treatment pictures, with a very positive impact on the patient’s quality of life.

The-Ezra-Clinic_Before-After_17

Our philosophy

Our approach to TED is comprehensive, and highly patient focussed. Our clinicians have extensive experience in managing TED, with particular specialisms in managing the inflammatory components of the condition and also ensuring that the aesthetic rehabilitation is executed to the highest possible standards. Our combined research output is extensive and includes a wide body of work on the impact on TED on Quality of life, the role of aesthetic interventions, new biologic treatments such as Tepezza (Teprotumumab), and immunosuppression.

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