About 1 percent of people in the United States have a type of hyperthyroid condition called Graves’ disease, according to the American Thyroid Association, If you’re one of them, you may be at risk for a complication called thyroid eye disease, or Graves’ ophthalmopathy.
- It is characterized by inflammation and swelling of tissues surrounding the eyes, which can trigger symptoms such as bulging eyes (proptosis) and double vision.
- While medical interventions, such as corticosteroids, biologics, and surgery, are among the first lines of defense for treating the disease, there are other lifestyle tips and over-the-counter products that you can use to supplement these treatments.
“Natural treatments, when used in conjunction with prescription treatments, are very useful ways of treating the symptoms of thyroid eye disease,” says Yuna Rapoport, MD, MPH, an ophthalmologist and the director and founder of Manhattan Eye, in New York City.
- 1 What triggers thyroid eye disease?
- 2 How long does it take for thyroid eye disease to go away?
- 3 Is thyroid eye preventable?
- 4 How common is thyroid eye disease?
Can you get rid of thyroid eye disease?
Thyroid Eye Disease Center The eye changes associated with thyroid disease are referred to as Thyroid Eye Disease (TED). Your doctor may also use the term Thyroid Associated Orbitopathy (TAO). Although TED is seen in all types of thyroid disorders, it is most common in patients that are or were hyperthyroid.
- It also rarely occurs in those who are hypothyroid and even when there is an absence of thyroid abnormalities in the body.
- Thyroid disease can cause multiple eye problems.
- These include redness and swelling, double vision, decreased vision, eyelid retraction (inability to close the eyes), and a bulging of the eye itself.
It is important to realize that if one of these occurs, it does not mean you will necessarily get all the other symptoms too. Eye problems will usually occur and frequently change in type or severity for between six months and two years. Once stabilized, it is unusual for the eyes to start changing again.
- Some patients are left with permanent changes, and in others the eyes return to normal.
- A great deal can be done to improve these conditions with medical treatment, although some patients will need surgery to help ease their issues.
- TED is usually associated with systemic (generalized) hyperthyroidism or Graves’ disease.
This disease is caused by what is described as an autoimmune process. Autoimmune disease may be understood as a process by which the body sees some part of itself as being foreign and reacts to it much the same way that it would to any bacteria or virus.
In the case of Graves’ disease, the body sees the thyroid gland as the foreign object and produces antibodies that attack the thyroid gland. This often causes the thyroid gland to become over active. The eye version of this disease is called Thyroid Eye Disease. However, in the case of TED, different antibodies attack the muscles associated with eye and eyelid movement.
Although the thyroid gland and the eye may be under attack by the same immune system, it is felt that both conditions remain mostly independent of one another. The antibodies that attack the eye can cause inflammation and swelling of the fat and muscles around the eye, which is what can eventually cause bulging of the eyes, double vision and retraction of the eyelids.
Will my eyes go back to normal after treatment? Most patients think once their medical doctor treats the body’s thyroid problem the eyes will go back to normal. This is often not the case. In some patients the eyes worsen in the months and years after medical treatment despite the body being stabilized.
Even though good medical treatment may not prevent or cure TED, it is extremely important to treat the thyroid abnormality and keep your body in proper thyroid balance. Your specialist can provide simple solutions to the irritation, tearing and swelling often associated with TED.
Often, this involves something as simple as using artificial tears during the day and lubrication ointment at night. Your specialist can determine when your eyes have stopped changing and whether corrective surgery is needed. Your specialist may also watch for the rare serious problems associated with TED that need prompt treatment.
Dry irritated eyes TED may cause you to experience dry, irritated and often teary eyes. This is usually due to the eyelids retracting and or protruding. When the eyelids do not close completely at night, the cornea (clear front portion of the eye) dries out and becomes quite uncomfortable.
- The use of lubricating ointment for the eye at night and artificial tears during the day can provide a great deal of relief.
- Do not be afraid to use the tears frequently, as much as every 1/2 to 1 hour if necessary.
- Double vision TED can cause swelling, irritation and scarring of the muscles that move the eyes.
This can lead to double vision. Double vision may not be present all the time, sometimes it is noticeable only when looking in certain directions, while in other patients it is always present. Often the amount of double vision will change week to week.
- At times it can disappear completely without treatment.
- Once the double vision has been stable for at least several months, surgery can be performed to correct it if necessary.
- Your specialist will refer you to a specialist for the surgery.
- Eyelid retraction TED can cause scarring in the eyelid muscles.
This scar tissue contracts or shortens, causing the eyelid to retract and increasing the white showing above and below the colored part of the eye. The amount of retraction tends to be variable, often changing week to week. In some patients the retraction will disappear with time.
- In addition to contributing to an unusual appearance of the eyes, the eyelid retraction can cause significant dryness, irritation and tearing.
- Light sensitivity is another common complaint.
- Severe drying of the front of the eye can occasionally lead to vision loss.
- It is usually preferred to wait for the eyelid position to stop changing before proceeding with surgery.
Surgery involves moving the eyelids into a more normal position. In the upper eyelids this is usually performed by removing or stretching the scarred muscles. In the lower eyelids, a graft is often needed to help push the eyelid upward. Eyelid repositioning can make a tremendous difference in both the feel and appearance of the eyes.
- Eye protrusion TED can cause an accumulation of fluid in the fat and muscles around and behind the eye.
- This can push the eye itself outward making it much more prominent.
- Coupled with eyelid retraction this can alter the appearance and comfort of the eye.
- Although less variable than eyelid retraction, the protrusion of the eye can return to normal on its own.
After being stable for several months or more, it is sometimes desirable to surgically move the eye into a more normal position. This can be accomplished by removing a portion of the bones surrounding the eye. The swollen fat and muscles around the eye can then fall into the extra space, allowing the eye to move backward.
This can go a long way toward returning the eyes to their pre-thyroid appearance and relieve the relentless pressure and irritation most patients feel around their eyes. Vision loss Decreased vision can occur in TED for several reasons. Exposure and irritation of the cornea (clear front portion of the eye) occurs secondary to eyelid retraction and eye protrusion.
Drops, ointment, eyelid repositioning or eye repositioning may be needed depending on the patients needs to improve vision. The other cause of decreased vision, but more rare, is compression of the main nerve from the eye to the brain. This occurs behind the eye when the muscles that move the eye become extremely swollen and press on the nerve.
If your vision decreases significantly, bring this to the doctor’s attention promptly. Often, medications taken by mouth will return vision to normal. Surgery and/or radiation treatments are occasionally necessary to restore vision. Many people with TED have eyes that appear to have prematurely aged. Swelling of the eyelids is one of the reasons for this.
Additionally, a fluid accumulation in the normal fat around the eyes causes this fat to bulge outward becoming visible as “bags” of the eyelids. If this does not go away on its own, it can be surgically removed. Although thyroid disease can cause multiple problems with the eyes, there is quite a bit that can be done to help.
Once your eyes have stabilized, we can plan a course of treatment to correct the problems you find to be most troublesome. It will often be necessary to come to the office several times over several months so we can measure and examine your eyes. Bring old photographs that show your face when you were younger and before you developed the eye/orbit disease.
These can be useful during your initial office visit. Photographs from before your eyes were affected by the thyroid condition and more recent ones that show how long your eyes have looked abnormal can be very helpful. Together, with patience and perseverance, we can do a lot to return your eyes to a more normal appearance and comfort level.
Chief of the Division of Oculofacial Plastics, Orbital and Reconstructive Surgery Ophthalmology, Oculofacial Plastic Surgery and Ophthalmology Portland
: Thyroid Eye Disease Center
What triggers thyroid eye disease?
Endocrine Connection – Graves’ disease is an autoimmune condition caused by immune cells attacking the thyroid gland, which responds by secreting an excess amount of, This increase in the production of thyroid hormone levels is driven by stimulation of the thyroid-stimulating hormone (TSH) receptor (TSHR), which is mainly located in the thyroid gland but is also found in other tissues such as the tissues around the eyes. Sometimes, the anti-TSHR antibodies, which are present in virtually all patients with TED, also bind to TSH receptors located in tissues around the eyes, resulting in TED. The levels of these antibodies can determine the severity and prognosis of TED. Approximately one-third of patients with Graves’ disease have some signs and/or symptoms of TED, while only 5% have moderate-to-severe TED. About 90% of patients with TED have hyperthyroidism. Hyperthyroidism and TED are due to the same underlying autoimmune process. In the active phase of TED, fluctuations in the levels of thyroid hormone (both underactive as well as overactive) can lead to progression of TED. In patients with Graves’ disease who undergo treatment with radioactive iodine therapy, it is important to closely monitor thyroid levels afterwards as untreated hypothyroidism (low thyroid hormone levels) can worsen TED. In hyperthyroidism, there is an excess level of thyroid hormone in the body. This is often characterized by a low thyroid stimulating hormone (TSH) level and high free T4 and T3 levels. Fluctuating levels of thyroid hormone can often worsen the eye disease. In TED, the immune cells that attack the thyroid gland (to cause Graves’ disease) also attack adipose (body fat) and fibroblast tissues around the eyes. TED, or Graves’ eye disease, is an autoimmune condition that is mainly driven by stimulation of the thyroid-stimulating hormone (TSH) receptor (TSHR). This receptor is mainly located in the thyroid gland but is also found in other tissues in the body such as the tissues around the eyes. The interaction between anti-TSHR antibodies, which are present in virtually all patients with TED, and TSH receptors in tissues around the eyes result in inflammation and swelling of the tissues around the eye. The levels of these antibodies can determine the severity and prognosis of TED. The anti-TSHR antibodies can also affect the skin (there is a lesser extent of skin involvement than eye involvement), causing a condition known as thyroid dermopathy or pretibial myxedema. This is usually noticed as thickening and puckering of the skin of the shins. Other signs are clubbing of the fingers and toes. A 7-point clinical activity score can be used to determine whether the TED is in the active or the inactive phase. Elements of the clinical activity score includes presence of pain with eye movement, redness of the eyelids and/or conjunctiva, swelling of the eyelids and/or conjunctiva, decreased eye movements and/or visual acuity, and severity of eye protrusion. A score of >/= 3 is suggestive of active disease. Disease severity can also be based on the likelihood of developing loss in vision and degree/severity of the eye protrusion observed. It is important to identify whether the disease is in the active phase as it is more likely to respond to treatment. The active phase of TED usually lasts two to three years and requires careful monitoring by an ophthalmologist until the disease is stable. Treatment during the active phase of the disease is focused on preserving sight and the integrity of the cornea. Symptoms and Risk Factors While some patients may not have any symptoms, at least half the patients with TED will report symptoms, which are due to inflammation and swelling of the tissue around the eye. Eye symptoms include dry eyes, itching and gritty sensation, increased tearing, puffiness around the eyes, redness and double vision. Some individuals may also report light sensitivity. The most common signs of TED are increase prominence or bulging of the eyes, redness in the eyes and eyelid swelling. A small proportion of patients with TED will have more serious complications including pain, loss of vision (due to compression of the optic nerve), and ulcerations on the cornea (due to incomplete closure of the eyelids). About 3-5% of patients with TED will have visually threatening complications including loss of vision (when swollen tissues compress the optic nerve) and corneal ulcerations (due to incomplete closure of the eyelids). Several risk factors have been identified in the development of TED including genetics and family history, sex (women are at a higher risk than men), cigarette smoking, and treatment with radioactive iodine treatment. Both first and second-hand smoking increases the risk of progression of TED and decreases the response to treatment in TED. The risk from smoking is proportional to the number of cigarettes smoked per day. Other conditions such as advanced age, stress, poorly controlled diabetes mellitus and uncontrolled thyroid disease are other likely risk factors. Prevention of disease progression is usually centered around the avoidance of cigarette smoking and refraining from the use of radioactive iodine for treatment of Graves’ hyperthyroidism in patients with moderate-to-severe or sight-threatening TED. In addition, trauma is also considered a stimulus for the development of TED. The goal of treatment is to achieve normal thyroid function. This can be achieved by using medications such as beta-blockers and thioamides. These medications help in reducing the symptoms of an overactive thyroid gland as well as decreasing the production of thyroid hormones. Another option to achieve normal thyroid function is surgery. Radioactive iodine can worsen TED and is generally not recommended in individuals with moderate-to-severe or sight-threatening eye disease. In individuals with mild eye disease, radioactive iodine can be considered as initial treatment. However, this should be done in conjunction with the concurrent use of glucocorticoids especially if they smoke or have high titers of the TSHR antibody. All patients should be advised to refrain from smoking. The following local measures can be helpful to alleviate some of the symptoms caused by TED: apply cool compresses to the eyes, elevate the head of your bed, use of artificial tears throughout the day and gels or ointments at night to prevent dryness, and protective eyewear and corrective lenses such as prisms for double vision. For individuals with mild disease, Selenium 100 mcg twice a day has shown some benefit. For individuals with moderate-to-severe or progressive eye disease, glucocorticoids can be used either orally or via the intravenous route. For steroid refractory TED, teprotumumab (insulin-like growth factor-1 antibody) may be a treatment option. Other therapies include external orbital radiation and orbital decompression. The diagnosis of TED is usually made clinically. To determine the severity of TED, your physician may perform the following tests to assess your vision and the changes in the tissues around your eyes: vision testing, visual fields testing, eyelid measurements, checking the optic nerves, and sometimes photographs. Laboratory finding are performed to evaluate for hyperthyroidism. CT or MRI scans can be performed in individuals who have moderate to severe eye disease to assess the risk of further complications. Referral to an ophthalmologist for evaluation of TED and subsequent management, and referral to an endocrinologist for evaluation and management of thyroid disease is encouraged. Questions for Your Healthcare Provider
What are the symptoms that I should be monitoring for to assess for whether the TED is worsening? When do I seek urgent care? What can I do to prevent further worsening of the TED? For patients who also have Graves’ disease and are considering treatment with radioactive iodine: Based on my risk factors, am I a candidate for prophylactic corticosteroid therapy after radioactive iodine to prevent worsening TED? For patients who have active, progressive TED regardless of their history of prior TED treatment: Based on my current disease state, am I a candidate for teprotumumab?
Editor(s): Andrea Kossler, M.D., FACS, Palak Choksi, M.D., Brandon Pham, Debbie Chen, M.D. Last Updated: January 24, 2022 Endocrine Society.”Thyroid Cancer | Endocrine Society.” Endocrine.org, Endocrine Society, 18 January 2022, http://admin.endocrine.org/?sc_mode=edit&sc_itemid=%7bE64BCF38-1719-40E3-85C8-3BA275BFFB54%7d&sc_version=1&sc_lang=en&sc_site=endocrine : Thyroid Eye Disease
How do they treat thyroid eye?
Tests and Diagnosis – If your doctor suspects you have an overactive thyroid gland, your thyroid function must first be evaluated and treated appropriately by an internist trained in doing so. Treatments include medications to suppress the production of hormone by the thyroid gland, radioactive iodine to eliminate hormone-producing cells, and surgery to remove the thyroid tissue.
In most cases, replacement thyroid hormone is required following the natural course of the Graves’ autoimmune attack on the thyroid gland or following effective treatment. Once your thyroid function is treated and returned to normal, the eye disease must be monitored as it often continues to progress.
Eye involvement must be evaluated on a continuing basis by an ophthalmologist during the active phase of the disease and, if necessary, treated. Although symptoms often resolve on their own, activity, scarring, and visual loss not readily apparent to the patient may otherwise go unnoticed and cause permanent changes.
How can I reverse my thyroid eye?
M anagement of thyroid eye disease has shifted dramatically from conservative measures—observation and surgery—to targeted biologic therapy with a focus on cosmesis and quality of life. Surgical innovations have also allowed for more profound results with significantly less risk of complications.
|Figure.1. Eyelid swelling and ocular redness in a patient with thyroid eye disease (top). Improvement in redness and swelling after orbital steroid injection (bottom).|
Medical Therapies Medical therapy can be a good initial, noninvasive way to manage certain patients with TED. Following are the pros and cons of the various medical approaches. • Vitamins. As discussed in part one of this series, data has shown that supplementation of selenium has reduced the severity and progression of disease in patients with mild thyroid eye disease.1 Dosing is at 100 µg daily, and is best started as early as possible in the course of the disease, preferably within six months of onset.
While there have been no studies of vitamin D supplementation in patients with TED, laboratory studies have shown an anti-inflammatory effect. Checking vitamin D blood levels and supplementing appropriately does little harm to TED patients, and may even be helpful. Beyond this, a good multivitamin and a healthy diet low in fats and processed food is beneficial for both gastrointestinal and overall health.
And of course, the number-one piece of advice for patients: Stop smoking. • Topical medicines. Topical eye drops are chiefly prescribed to treat ocular surface disease. In the early, active phase of TED, ocular surface inflammation contributes to dry eye; this often responds to a low-dose topical steroid such as loteprednol or fluorometholone.
In the later, stable phase of the disease, chronic exposure is the main cause of dry eye and can be addressed with lubrication—a regimen of artificial tears, gel and nighttime ointment is often necessary. While surgery may eventually be required, an aggressive topical regimen can greatly improve the quality of life for patients suffering with TED.
• Steroids. Steroids are excellent for reducing symptoms in TED, but aren’t disease-modifying; rather, they improve soft-tissue symptoms in the active phase until the body can pass into the stable phase of the disease. Steroids can be given as direct injections into the orbit, as pills or as intravenous infusions.
|Figure 2. Bilateral proptosis in a patient with thyroid eye disease (top). Dramatic reduction in proptosis seen after orbital decompression surgery (bottom).|
In Europe, nearly every patient with a diagnosis of thyroid eye disease receives intravenous infusions of steroid once weekly for 12 weeks.2 Intravenous steroids have been shown to have a greater efficacy than oral steroids (80 percent vs.50 percent).
- While this doesn’t cure the disease, it does reduce the clinical severity and improve the patient’s quality of life.
- However, 10 percent of patients are resistant to steroids.
- Steroids also carry the significant risks of liver failure, diabetes, insomnia, psychological changes and even death (if the cumulative dose exceeds 6 to 8 g).
Since the treatment doesn’t alter the course of the disease, the decision of whether or not to undertake a course of intravenous steroids after a new diagnosis of thyroid eye disease is a very personal one and the patient and physician should discuss it in detail.
The exception is for patients who are experiencing vision loss: Up to half of patients with optic nerve damage from thyroid eye disease may be able to avoid immediate surgery, or avoid surgery altogether, with a course of intravenous steroids.3 • Orbital radiation. This may sound scary, but it’s a relatively gentle treatment considering the small doses that are used for TED.
Radiation is helpful in patients who have persistent inflammation in active disease, and it’s synergistic with steroids (i.e., the combined effect of radiation and steroids together is greater than either alone). Treatment is typically given in 10 sessions over two weeks, with a total dose of 20 Gy, which is well below the dose required to cause retinal damage (35 Gy) or nerve damage (50 Gy).
|Figure 3. Patient with visual compromise, orbital congestion and pain from thyroid eye disease (top). Improvement in cosmetic appearance, as well as vision, orbital congestion and pain after decompression surgery (bottom).|
Biologic therapy. Biologic therapy, or customized molecular medicines that specifically target the abnormal biochemical pathways in thyroid eye disease, are a promising hope for the future. These include currently available medicines such as adalimumab (Humira), infliximab (Remicade) and etanercept (Enbrel), as well as many medicines yet to be approved.
Unfortunately, these drugs are quite expensive, precluding a large-scale randomized trial from being conducted. At the same time, insurance companies are hard-pressed to approve a medicine that hasn’t been proven in a trial. As such, physicians are left with weak studies that are little more than anecdotes about clinical improvement with these medicines.5 Rituximab is a medicine well-described in its use against lymphoma.
It targets the immune cells that produce antibodies (B-cells), and physicians were initially very hopeful that there would be a clinical effect in patients with TED. Two large, randomized, controlled, concurrent trials were conducted: one in Europe and one in the United States.6,7 Unfortunately, the results were conflicting, with the European study suggesting a beneficial effect of rituximab 6 and the United States study showing no improvement.7 While there are technical explanations for these confusing results, the bottom line remains that there is no clear evidence that rituximab improves the course of TED.
- Tocilizumab (Actemra, Genentech) is a potent biologic medicine that was initially used for other severe autoimmune diseases such as giant cell arteritis.
- There have been case reports of improvement in TED, 8,9 and Genentech recently completed a randomized, controlled trial, the results of which are pending.
The most exciting drug to be developed in recent memory for thyroid eye disease is surely teprotumumab (RV 001). Teprotumumab is an antibody directed against IGF-1, the growth factor pathway associated with the thyroid-hormone receptor. Teprotumumab is the only medicine to date proven to reduce overall clinical severity and proptosis, and provide a sustained response.10 In other words, teprotumumab can halt progression of active disease and reverse any changes associated with TED, and the effects are long-lasting.
|Figure 4. Eyelid retraction (top) with improvement in upper lid position after eyelid retraction surgery (bottom).|
Overall, biologic medicines and targeted molecular therapy are the wave of the future. More research is needed, but patients with TED live in exciting times, as these new medicines can truly be life changing. Surgical Therapies Surgery for TED is often necessary, but is usually delayed until the disease is in its stable phase. There’s a small (<10 percent) risk of reactivating the active phase of the disease after surgery, though this is rare. The surgical options consist of the following: • Orbital decompression. Orbital decompression surgery is the mainstay of rehabilitation for TED; it can improve nearly every aspect of the disease, from vision-threatening optic nerve damage or corneal exposure (Figure 2) to cosmesis (Figure 3), Quality of life is often better after surgery, since orbital congestion, pain and dry eye can improve. Common complications include double vision and scarring (5 to 25 percent, depending on the technique used), while rare complications include vision loss (<0.5 percent, partial or total in the operated eye), though these can be minimized with newer, minimally invasive techniques.11,12 Surgery is performed under general anesthesia through invisible skin incisions hidden in the natural folds of the eyelids, takes 60 to 90 minutes, and is performed on an outpatient basis. • Strabismus surgery. Surgery to adjust the extraocular muscles and improve double vision is commonly performed. However, this can be much more complicated than typical strabismus surgery, and needs to be performed by a surgeon who is experienced in thyroid eye disease. This surgery takes between 30 to 60 minutes, can be performed under general or twilight anesthesia, and is done on an outpatient basis. Patients can have significant improvement if the muscles aren't too scarred. • Eyelid surgery. Surgery to improve eyelid retraction is often the final step in rehabilitation. This step can also be the most temperamental, as the eyelid structures are incredibly minute and unpredictable. However, significant improvement can be achieved (Figure 4), Surgery is performed under twilight anesthesia, can take between 30 to 60 minutes, and is done on an outpatient basis. • Cosmetic surgery. While thyroid eye disease primarily affects the tissues inside the orbit, there are significant changes in the skin and fat in the eyebrows, cheeks, neck and other areas of the face. In fact, the eyebrow and cheek fat tends to grow alongside the orbital fat, creating a characteristic "hourglass" appearance (Figure 5), These various changes can be addressed with a combination of lasers, fillers, botulinum toxin (i.e., Botox), or even surgery for the eyelid, eyebrow, face and neck. Great care must be taken when undergoing cosmetic surgery in the context of thyroid eye disease: Treating a TED patient like any other cosmetic surgery patient can, at best, lead to a hollow, unnatural look and, at worst, lead to severe corneal exposure and loss of vision or even loss of the eye.
|Figure 5. Fat growth in the brows and lower lids and cheeks after thyroid eye disease, causing an “hourglass” deformity.|
Future Directions With all the exciting research and medical and surgical innovations that have come to fruition in the past several years, it’s an exciting time for patients with thyroid eye disease. In an ideal world, we’d be able to predict exactly which patients with Graves’ disease will develop thyroid eye disease, treat them with a medicine to prevent TED, and reverse any clinical manifestations that may have already occurred.
This goal is within reach, since game-changing new medicines that can halt and reverse symptoms of TED are in the pipeline, and the focus has shifted from simply preserving vision to enhancing such things as cosmesis and quality of life. REVIEW Dr. Ramesh is a clinical assistant professor of ophthalmology at Sidney Kimmel Medical College at Thomas Jefferson University, and a member of the Wills Eye Hospital Orbital and Oculoplastic Surgery Service.
He practices at Eye and Facial Plastic Surgery Consultants in Langhorne, Pennsylvania. His areas of interest include TED, facial trauma and cosmetic facial and eyelid procedures.1. Marcocci C, Kahaly GJ, Krassas GE, et al. Selenium and the course of mild Graves’ orbitopathy.
- N Engl J Med 2011;364:20:1920-31.2.
- Bartalena L, Baldeschi L, Boboridis K, et al.
- The 2016 European Thyroid Association/European Group on Graves’ Orbitopathy guidelines for the management of Graves’ orbitopathy.
- Eur Thyroid J 2016;5:1:9-26.3.
- Wakelkamp IM, Tan H, Saeed P, et al.
- Orbital irradiation for Graves’ ophthalmopathy: Is it safe? A long-term follow-up study.
Ophthalmology 2004;111:8:1557-62.4. Prummel MF, Terwee CB, Gerding MN, et al. A randomized controlled trial of orbital radiotherapy versus sham irradiation in patients with mild Graves’ ophthalmopathy. J Clin Endocrinol Metab 2004;89:1:15-20.5. Ayabe R, Rootman DB, Hwang CJ, et al.
- Adalimumab as steroid-sparing treatment of inflammatory-stage thyroid eye disease.
- Ophthalmic Plast Reconstr Surg 2014;30:5:415-9.6.
- Salvi M, Vannucchi G, Curro N, et al.
- Efficacy of B-cell targeted therapy with rituximab in patients with active moderate to severe Graves’ orbitopathy: A randomized controlled study.
J Clin Endocrinol Metab 2015;100:2:422-31.7. Stan MN, Garrity JA, Carranza Leon BG, et al. Randomized controlled trial of rituximab in patients with Graves’ orbitopathy. J Clin Endocrinol Metab 2015;100:2:432-41.8. Perez-Moreiras JV, Alvarez-Lopez A, Gomez EC.
- Treatment of active corticosteroid-resistant graves’ orbitopathy.
- Ophthalmic Plast Reconstr Surg 2014;30:2:162-7.9.
- Sy A, Eliasieh K, Silkiss RZ.
- Clinical response to tocilizumab in severe thyroid eye disease.
- Ophthalmic Plast Reconstr Surg 2017;33:3:e55-e7.10.
- Smith TJ, Kahaly GJ, Ezra DG, et al.
- Teprotumumab for thyroid-associated ophthalmopathy.
N Engl J Med 2017;376:18:1748-61.11. Ramesh S, Nobori A, Wang Y, et al. Orbital expansion in cranial vault after minimally invasive extradural transorbital decompression for thyroid orbitopathy. Ophthalmic Plast Reconstr Surg 2018; 2018 Jun 6. (epub ahead of print).12.
How long does it take for thyroid eye disease to go away?
Thyroid Eye Disease – Prevent Blindness Eye Diseases & Conditions Thyroid eye disease (TED), sometimes called Graves’ ophthalmopathy or, is an in which the immune system causes inflammation and swelling and stimulates the production of muscle tissue and fat behind the eye. The overactive ( ) is usually caused by Graves’ disease.
Up to one-half of people with Graves’ disease develop thyroid eye disease. In some people, thyroid eye disease can occur with normal levels of thyroid hormones (euthyroid) or low levels of thyroid hormones ( ). Thyroid eye disease may occur in patients who already know they have thyroid disease, or it may be the first sign of Graves’ disease.
While TED often occurs in people living with hyperthyroidism or Graves’ disease, it is a distinct disease and treating hyperthyroidism may not resolve the eye symptoms and signs. In the “active phase” of thyroid eye disease, the main symptoms include inflammation and increased amounts of the tissue, muscles, and fat behind the eye (in the bony eye socket) causing the eyeballs to bulge out.
If the eye is pushed far enough forward, the eyelids may not close properly when blinking and sleeping. The front part of the eye, called the cornea, may become unprotected, dry and, damaged. Also, the enlargement of the tissues and muscles of the eye may prevent it from working well, which affects eye position and eye movements leading to double vision.
In severe cases, the inflammation and enlargement of the tissues, muscles, and fat behind the eye compresses the optic nerve, the nerve that connects the eye to the brain, causing vision loss. Thyroid eye disease is most commonly associated with Graves’ disease.
Age: Usually affects middle-age adults but can occur at any age Gender: Females are affected more than males Family history of thyroid eye disease Smoking: Smoking increases the risk of thyroid eye disease by 7–8 times, causes thyroid eye disease to have a longer “active phase”, and it reduces the effectiveness of treatments Radioactive iodine therapy: Radioactive iodine has been used to treat hyperthyroidism and Graves’ disease. This treatment should be used with caution in people with active thyroid eye disease as it may worsen the condition unless steroids are given at the same time Low blood levels of selenium, a dietary mineral.
If you have Graves’ disease, eye symptoms most often begin within six months of disease diagnosis. Very rarely, eye problems may develop long after the Graves’ disease has been treated. In some patients with eye symptoms, hyperthyroidism never develops and, rarely, patients may have hypothyroidism. Dry, gritty and irritated eyes Red eyes Watery eyes Puffy eyelids Sensitivity to light Bulging eyes (called proptosis) and lid retraction – giving a staring or startled appearance In more advanced thyroid eye disease, there may also be:
Trouble moving eyes and closing eyes Inability to completely close your eye causing a corneal ulcer Colors appear to be dull or not as bright Blurred or loss of vision due to optic nerve compression or corneal damage
Double vision Thyroid eye disease in its active phase can last between one and three years. That means if it is left untreated, the inflammation may gradually decrease by itself but may cause damage to vision through the course of the disease. Sometimes, the changes caused by the enlargement of the tissues (such as bulging eyes or double vision) may not go away.
- The goal of treatment is to limit inflammation and swelling occurring during the active or inflammatory phase and to protect the front of the eye and prevent vision loss.
- Thyroid eye disease is managed by a specialist eye doctor (ophthalmologist).
- Any underlying thyroid problems will be managed by your primary care doctor (PCP) or by a specialist in the hormone systems of the body (an endocrinologist).
If a thyroid issue is suspected, evaluation and treatment are critical. The first priority is to restore your normal thyroid function. In addition, eye conditions should be examined and treated at the same time as your thyroid gland treatment. Eye problems may continue to progress even after your thyroid function returns to normal.
If you have thyroid eye disease, your eye doctor may recommend one or more of the following treatments to help soothe your eyes and improve your vision: Cool compresses : Apply cool compresses to your eyes. The extra moisture and cooling effect may provide relief. Sunglasses : When you have thyroid eye disease, your eyes are more sensitive to sunlight and UV rays.
Wearing sunglasses helps protect them from both sun and wind. Lubricating eye drops : Use lubricating eye drops, like artificial tears. It may help relieve dryness and scratchiness. Make sure to use eye drops that do not contain redness removers. Lubricating gels can be used before bed to prevent the cornea (the front of the eye) from drying out because your eyelids may not close completely when sleeping.
Note: If you have difficulty closing your eyelids, you may be at risk to develop a corneal ulcer. The cornea is a clear layer that covers the front of the eye. A corneal ulcer is an open sore on your cornea and it can cause scarring and permanent loss of the vision. A corneal ulcer causes redness of the eye, pain and usually a decrease in vision.
You should seek immediate attention from your eye doctor for these problems. Taping: Talk with your doctor about taping your eyelids together to help protect your front of your eye (cornea) from drying when your eyelids do not close completely during sleep.
- Elevate your head when laying down : Keeping your head higher than the rest of your body may reduce swelling and may help relieve pressure on your eyes.
- Quit smoking : Smoking (and second hand exposure to smoke) is an important risk factor for thyroid eye disease.
- If you smoke, quit, and avoid second hand smoke.
Steroids : Swelling in your eyes may be improved by treatment with steroids (such as hydrocortisone or prednisone). Your doctor may recommend either intravenous or oral medication. Note, make sure you discuss the risks of use of steroids with your doctor before use.
Selenium supplements : Recent studies suggests that patients with mild active thyroid eye disease may benefit from selenium supplements. Talk to your doctor before starting supplements. Prisms : Thyroid eye disease can cause scar tissue to develop in your eye muscles. This can lead them to become short and pull your eyes out of alignment, causing double vision.
If double vision occurs, glasses containing prisms may be prescribed by your doctor. However, prisms do not work for all people with double vision and your doctor may recommend patching one eye for temporary relief or eye muscle surgery as a more effective option when changes have stabilized.
- Eyelid surgery : When you have thyroid eye disease, the eyelids are usually more widely open with a “startled look” because the muscles in the eyelids may tighten and pull the upper lid up and the lower lid down.
- You may have difficulty closing your eyelids, leaving the front of the eye (cornea) more exposed, which causes tearing, irritation and susceptible to developing a corneal ulcer.
Eyelid surgery may help reduce exposure of the cornea. Eye Muscle Surgery : Eye muscle surgery may help correct your double vision by moving the affected muscle farther back from its original position on the eyeball. This surgery will help to correct your double vision when reading and looking straight ahead.
Sometimes, you may need more than one surgery to get effective results. Orbital Decompression Surgery : Thyroid eye disease can cause swollen tissues around the eye that compresses the optic nerve. The optic nerve provides the connection between your eye and the brain. When the nerve is compressed, color vision becomes abnormal, lights may seem dimmer than usual, and the sharpness of the vision decreases.
Orbital decompression surgery can be done to improve your vision. The surgery makes the eye socket bigger or removes some of the excess tissue. When the nerve is compressed, the goal of surgery is to get the eye and the inflamed tissue more space and decreases pressure on the optic nerve.
Even when the optic nerve function is not compromised, orbital decompression may be used to restore comfort and appearance by reducing the bulging of the eyes. If orbital decompression surgery is recommended, it is usually performed prior to eye muscle surgery and/or eyelid surgery, if needed. New treatments: There is an intravenous infusion (putting drugs into a vein) treatment that is the first FDA-approved medication for the treatment of thyroid eye disease.
Your eye doctor will require some time for your thyroid eye disease to stabilize before recommending surgery. Typically, the active or inflammatory stage of thyroid eye disease lasts one to three years. During this time, your eye doctor will avoid surgically treating your symptoms unless your vision is threatened.
In cases such as a corneal ulcer or optic nerve compression urgent surgery may be recommended. Thyroid Gland: The thyroid gland is located in the front of your neck. It produces thyroid hormones that are sent to the blood and carried around to other parts of your body. These hormones help your body use energy, stay warm and keep the brain, heart, muscles, and other organs working normally.
The thyroid gland can become overactive (hyperthyroidism) or underactive (hypothyroidism). This is most often due to an autoimmune disease in your body. Hyperthyroidism : Hyperthyroidism is a condition where the thyroid gland is stimulated by the immune system to produce more thyroid hormones than are needed by the body.
- Symptoms may include weight loss, nervousness, irritability, increased perspiration, fast heart rate, hand tremors, difficulty sleeping, thinning of the skin, brittle hair, and frequent bowel movements.
- Hypothyroidism : Hypothyroidism is a condition where thyroid gland function is blocked by the immune system and not enough thyroid hormone is produced for the body’s needs.
Symptoms may include feeling cold and tired, having drier skin, becoming forgetful and depressed, and having constipation. Autoimmune disease : If you have an autoimmune disease, your immune system mistakenly attacks your body. Autoimmune diseases can affect many parts of the body. TED can cause eye pain, double vision, loss of vision, and changes to your appearance which may impact your quality of life. The impacts of TED can lead you to experience to depression, anxiety, loss of independence, and reduced self-confidence. You may have a decreased desire to socialize with others, have trouble with productivity at school or work, and stop doing activities you once enjoyed.
Talk to your doctor : Talk to your doctor about any changes to your emotional well-being. Ask questions on how TED will affect your daily life and work. Seek support: Seek out support groups of others who are going through TED. The Graves’ Disease and Thyroid Foundation offers support groups for people with Graves’ disease, thyroid eye disease, and other thyroid conditions. These groups can help you learn about your condition, share your experience, and find support. Connect with others: Stay connected friends and family to keep you from feeling isolated. Take time to enjoy life : Take part in activities or hobbies that make you happy. Exercise : Exercise can help symptoms of depression or anxiety and make you feel better. Talk to your health care professional to determine what exercise routine may work best for you, especially if you have changes to your vision due to TED.
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This resource was made possible by the generous support of: : Thyroid Eye Disease – Prevent Blindness
Is thyroid eye preventable?
PREVENTION. Graves’ disease and usually the associated eye disease cannot be prevented. However, radioiodine therapy used to treat hyperthyroidism is more likely to worsen the eye disease and should be avoided, if possible in patients with moderate or severe eye disease.
Can thyroid be totally cured?
Can hyperthyroidism be cured? – Yes, there is a permanent treatment for hyperthyroidism. Removing your thyroid through surgery or destroying your thyroid through medication will cure hyperthyroidism. However, once your thyroid is removed or destroyed, you’ll need to take thyroid hormone replacement medications for the rest of your life.
How do I know if I have thyroid eye disease?
6. Double vision (diplopia) – In severe thyroid eye disease, double vision is always present, says Falcone. That’s because as the eye bulges forward, the muscles that surround the eye aren’t able to move properly, says Kossler. “With thyroid eye disease, people might have flares, or worsening of the redness, swelling, and grittiness, that go away,” says Falcone.
Is thyroid eye disease serious?
What Is Thyroid Eye Disease? Medically Reviewed by on October 14, 2021 Thyroid eye disease is an immune system disorder. It goes by a few other names. The immune system doesn’t function right in people with this condition. That leads to inflammation that causes the muscles and tissue around your eyes to puff up.
Thyroid eye disease can cause lots of symptoms. Some are mild while others are more serious. Often, your eyes will feel dry and “gritty.” You might get swelling that pushes your eyes forward or affects how you see. It’s rare, but you could lose your eyesight, too. There are treatments that can ease your symptoms and protect your vision.
You might need mental health support and social support, too. You may have heard thyroid eye disease called Graves’ ophthalmopathy, Graves’ orbitopathy, or Graves’ eye disease, but those terms are no longer used. Your immune system protects you from germs and other things that can make you sick.
- With thyroid eye disease, your body mistakes your own tissue in and around your eyes for a foreign invader.
- Your immune system then sends out cells called antibodies that attack the fat, muscle, and other tissue in and around your eye.
- Experts can’t say for sure what triggers this immune response in some people.
Researchers are still studying all the causes. The condition happens most often in people with too much thyroid hormone, or hyperthyroidism. Less commonly, it can happen if you have an underactive thyroid. Rarely, you can get it if you have normal thyroid levels.
- Graves’ disease is an immune system disorder that causes your body to attack your thyroid gland.
- The attack triggers your body into making extra thyroid hormone.
- Graves’ disease doesn’t cause thyroid eye disease.
- But the two conditions do show up around the same time.
- The disorders may arise together because the tissue around your eyes may have proteins that are similar to the kind in your thyroid gland.
If you have Graves’ disease, some other risk factors might raise your chances of getting thyroid eye disease, such as:
You smoke.You’re female.You have certain genetic factors.You get radioiodine treatment.
The condition can make your eyes bulge. That’s because it mostly affects your orbit, the area in your skull where your eyeballs sit. Immune cells can cause inflammation that make the muscles, fat, and other tissue in this area expand. If there’s a lot of swelling, you may not be able to close your eyes all the way. You may also get other symptoms, such as:
Redness in the whites of your eyesIrritation, like there’s dirt in your eyePain and pressureDry or watery eyesDouble visionLight sensitivity
Usually, there’s nothing you can do to stop thyroid eye disease from happening. But there’s evidence that radiation treatment with radioactive iodine, a treatment for overactive thyroid, can make eye disease worse. If you have this eye disease and you need this kind of therapy, your doctor may also give you a steroid called prednisone.
- That can help keep the disease under control.
- The disease acts differently in everyone.
- You might have inflammation that lasts from 6 months to 2 years.
- You may have lasting effects to your eyes even after the swelling goes down.
- Your symptoms might go away on their own.
- But your doctor can give you medicine, like steroids, or suggest at-home methods to help ease swelling and soothe your eyes.
If those aren’t enough, you may need surgery. Treatment for thyroid eye disease is different from what you get for Graves’ disease. Your eye problems can even show up after you treat your thyroid. For best results, you’ll need to work with a team of doctors, such as:
A primary care doctorAn eye care specialist (ophthalmologist or optometrist)A doctor who treats hormone system disorders (endocrinologist)Mental health counselor
Most people only have mild symptoms. But around 3%-5% of those with thyroid eye disease have serious problems, which could include vision loss. © 2022 WebMD, LLC. All rights reserved. : What Is Thyroid Eye Disease?
Is thyroid eye disease permanent?
Second stage: eye muscle surgery – In Graves’ eye disease, scarring can cause permanent damage to the eye muscles. Scar tissue, which forms around muscle fibers, becomes stiff and neither contracts nor relaxes as easily as the muscle it replaces. The eyes may then become misaligned, causing double vision.
- Eye muscle surgery can minimize double vision, but may not completely eliminate it.
- The goal of this surgery is to create a tunnel of single vision, allowing patients to achieve good straight-ahead vision needed for driving and reading.
- The patient is able to resume many activities, but still may experience double vision when looking far to the right or left.
The surgery is performed on an outpatient basis with local anesthesia. In eye muscle surgery, the surgeon repositions the muscles, bringing the eyes into alignment. The incisions are hidden. In approximately 5 to 10 percent of cases, more than one surgery is needed to achieve satisfactory alignment of the eyes.
Is thyroid eye rare?
General Discussion – Summary Thyroid eye disease is a rare disease characterized by progressive inflammation and damage to tissues around the eyes, especially extraocular muscle, connective, and fatty tissue. Thyroid eye disease is characterized by an active disease phase in which progressive inflammation, swelling, and tissue changes occur.
This phase is associated with a variety of symptoms including pain, a gritty feeling in the eyes, swelling or abnormal positioning of the eyelids, watery eyes, bulging eyes (proptosis) and double vision (diplopia). The active phase can last anywhere from approximately 6 months to 2 years. This is followed by an inactive phase in which the disease progression has stopped.
However, some symptoms such as double vision and bulging eyes can remain. In some people, cosmetic changes and significant disability can develop. Although uncommon, in severe instances, vision loss can occur. Thyroid eye disease is an autoimmune disorder.
An autoimmune disorder is one in which the body’s adaptive immune system, which protects the body from infectious or other foreign substances, mistakenly attacks healthy tissue instead. Introduction Thyroid eye disease most commonly occurs as part of Graves’ disease, which is an autoimmune disease that affects the thyroid and often the skin and eyes.
The thyroid is a butterfly-shaped gland located at the base of the neck. The thyroid is part of the endocrine system, the network of glands that secrete hormones that regulate the chemical processes (metabolism) that influence the body’s activities as well as regulating the heart rate, body temperature, and blood pressure.
Will removing thyroid stop thyroid eye disease?
As thyroidectomy removes all or nearly all thyroid tissue from the neck, this will result in a more rapid decrease in antibody production over time, which is beneficial for those with eye disease.
Are Graves disease eyes permanent?
Graves’ eye disease often improves on its own. However, in some patients symptoms may persist despite treatment of the overactive thyroid gland and specific eye therapies.
How common is thyroid eye disease?
Disease – Thyroid eye disease (TED) is an autoimmune disease caused by the activation of orbital fibroblasts by autoantibodies directed against thyroid receptors. TED is a rare disease, which had an incidence rate of approximately 19 in 100,000 people per year in one study.
The disorder characterized by enlargement of the extraocular muscles, fatty and connective tissue volume. Graves’ disease (GD) is an autoimmune disorder involving the thyroid gland, typically characterized by the presence of circulating autoantibodies that bind to and stimulate the thyroid hormone receptor (TSHR), resulting in hyperthyroidism and goiter.
Organs other than the thyroid can also be affected, leading to the extrathyroidal (outside the thyroid gland itself) manifestations of GD. TED is observed in ~ 50% of patients while Graves’ dermopathy and acropachy are quite rare. TED was previously known as thyroid-associated ophthalmopathy (TAO), Graves orbitopathy (GO) and other variations.