Thyroid orbitopathy (also known as Thyroid Eye Disease or Graves’ Disease) is an autoimmune inflammatory disorder of uncertain etiology that affects the tissues of the orbit (i.e. eyelids, extraocular 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.
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. Symptoms include eye pain or pressure, dry itchy eyes, tearing, redness, eyelid swelling, bulgy eyes (proptosis), double vision (diplopia) and blurred or even loss of vision. 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. A small percentage of patients with thyroid eye disease develop severe inflammation, which can result in compression of the optic nerve and permanent vision loss. In most cases, the inflammatory process is self-limited and runs a course lasting 6 months to one year 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 orbitopathy are usually evaluated on an interval basis to monitor progression of the disease and managed with measures (ocular lubricants and ointments) to reduce ocular symptoms. Cigarette smoking has been associated with development of worsening thyroid orbitopathy, therefore cessation of smoking is universally recommended in these patients.
Patients with moderate to severe orbitopathy may require medical or surgical intervention to reduce inflammation or improve vision. For pain or swelling, a short course of steroids may be used. Orbital radiation also has a role in more severe cases. Patients with severe thyroid eye disease need to be followed closely for the development of compressive optic neuropathy, which occurs in a small percentage of patients.
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 is an oculoplastic surgeon who uses the latest minimally invasive technique, through hidden incisions, to achieve the desired effect. 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.
Who Should Perform Ectropion Surgery?
Orbital decompression and eyelid reconstructive surgery should be performed by an oculoplastic surgeon. An oculoplastic surgeon specializes in the eyelids, orbit, and tear drain system. Their membership in the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) indicates he or she is not only a board certified ophthalmologist who knows the anatomy and structure of the eyelids and orbit, but also has had extensive training in ophthalmic plastic reconstructive and cosmetic surgery.
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