Thyroid orbitopathy, also known as Thyroid Eye Disease or Graves’ Disease, is an autoimmune inflammatory condition, related to the thyroid gland, that affects the different structures within the orbit (eye socket) and surrounding tissues including the eye muscles, orbital fat, and eyelids. The thyroid gland is also usually affected but the timing and severity of the thyroid gland disease and orbital disease can vary greatly. A small percentage of patients may have eyelid and orbital manifestations of the disorder without developing a thyroid abnormality.

Symptoms of Graves’ Disease

As stated earlier, the eye/orbit involvement in Graves’ Disease can range from very mild to very severe. The symptoms usually begin slowly but they can develop rapidly. The usual course of the eye disease is worsening over a year period, with subsequent “burning out”. It is during the “burned out” stage that rehabilitative surgery (bulgy or bulging eye surgery through orbital decompression, eyelid retraction surgery, and blepharoplasty) is usually performed.

Symptoms and signs also vary, depeding on the severity of the disease. These include eye irritation/dryness, eye pressure, tearing, redness, eyelid swelling, eyelid retraction, bulgy or bulging eyes (proptosis), double vision (diplopia) and blurred or even loss of vision. The vision loss can be significant eye dryness or exposure (secondary to bulgy eyes – proptosis) and/or from optic nerve compression.

Evaluation and Surgical Management of Graves’ Disease (orbital decompression, eyelid surgery)

The treatment of a patient with Graves’ disease is multidisciplinary, with help of endocrinologist, thyroid surgeon, ophthalmologist, and oculoplastic surgeon. The underlying problem, which is the thyroid gland, needs to be treated, which may include medications, radioactive iodine, and/or thyroid surgery. During the active inflammatory stage of the thyroid eye disesase, the eye symptoms are treated conservatively, including aggressive eye lubrication and possibly systemic medication (steroids). Smoking has been shown to worsen the eye pathology and hence quitting is highly recommended. Frequent monitering may be necessary, especially in severe cases with significant bulgy eyes and risk of optic nerve damage.

Surgical Treatment for Graves’ Disease (Thyroid Eye Disease)

Once the inflammatory phase of the disease has subsided, patients with eyelid abnormalities, double-vision or proptosis may be eligible for surgical correction to improve their function and appearance. The first stage of therapy is usually orbital decompression to reduce proptosis (protruded bulgy eyes) by expanding the eye socket (orbit) to allow the eye to move back. Dr Taban uses the latest minimally invasive technique, through hidden incisions, to achieve the desired effect. By making the orbit larger internally, the eyeball can sit back more into a more natural state, reducing or eliminating the appearance of bulging eyes. This is an outpatient surgery with about 7-10 days of postoperative swelling/bruising. Second stage surgery is for those with restrictive strabismus causing diplopia (double vision) not corrected by prism glasses. The third stage operation is eyelid surgery, both reconstructive (eyelid retraction surgery) and cosmetic (blepharoplasty). Eyelid retraction is a frequent abnormality of thyroid eye disease causing elevation of the upper eyelids, giving a “stared” look appearance. This can be corrected, along with bags around the eyes.

Before and after left upper lid retraction surgery and right upper lid ptosis surgery

Before (left) and 3 months after (right photo) of right upper eyelid ptosis surgery, left upper eyelid retraction surgery and bilateral lower blepharoplasty.

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Before (left) and 3-months after (right) bilateral orbital decompression and upper eyelid retraction surgery.

Before (left) and after (right) orbital decompression.

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