Thyroid Eye Disease

THYROID EYE DISEASE

Severe proptosis (protruding of eyes) and double vision.

Severe proptosis (protruding of eyes) and double vision.

Patient with thyroid eye disease/Graves disease usually present with bulging eyes (proptosis/ exophthalmos), start eye appearance (eyelid retraction), double vision (diplopia), watery eyes, red swollen eyes or reduced vision. It may present before they are diagnosed to have thyroid disease. While many have mild version of this condition, in some people it can progress rapidly and leading to significant reduction in vision, double vision and disfigurement.

It is important to note that either hyperthyroidism nor hypothyroidism can present with thyroid eye disease.

There are two phases of this condition: active and quiescent phase. The active phase can last for 18 months but it is not that uncommon that it can be reactivated again after quiescent for years. Patients with active thyroid eye disease should see an oculoplastics surgeon to reduce inflammation and degree of severity of disease.   When the eye has quieted down, surgery can be offered to improve double vision and restore facial appearance to its previous features.

TREATMENT

It is very important to seek attention of oculoplastic surgeon for the management of thyroid eye disease.  The routine administration of intravenous or oral prednisolone should be taken with care as we commonly see patients with Graves disease were given inappropriate dose of steroid leading to ineffective response and multiple steroid related side effect.

It is important for the oculoplastic surgeon to rule out other diagnosis before embarking on treatment.  Depending on the activity and severity of disease, an individualised approach can be adopted. During the active phase, artificial eye drops, sunglasses, sleep with head upright will help to reduce the swelling. Steroid may be given depends on condition. Indiscriminate giving of steroid is not encouraged due to its significant side effect. Intravenous steroid is favoured over oral steroid for its efficacy and reduced side effects. For those who has double vision, it can be temporarily relieved with occlusion or prism. Surgery such as orbital decompression may be required in rare instance of active severe thyroid eye disease which threaten the vision.

During the quiet phase,  squint surgery can be performed to correct the double vision meanwhile orbital decompression can be used to reduce bulging eye appearance or eye bags.  Eyelid retraction surgery with hard palate graft can be used to improve the starry eye appearance in lower eyelid and eyelid recession to lower down upper eyelid.

For the past few years, Dr Ho noted a link between emotional health with thyroid eye diseases, so with the diet may exert some influence on remission of this condition. Psychological counselling is provided or referral may be required if necessary. Advice on dietary intake is given as well.

Pre op: Severe proptosis and deviated eye (Squint) secondary to restricted muscle.

Pre op: Severe proptosis and deviated eye (Squint) secondary to restricted muscle.

Post op: Bilateral orbital decompression and hard palate graft to treat lower eyelid retraction. Partial success in right eye due to development of cicatricialsclerosing and response secondary to steroid.

Post op: Bilateral orbital decompression and hard palate graft to treat lower eyelid retraction. Partial success in right eye due to development of cicatricialsclerosing and response secondary to steroid.

Pre op and treatment: This boy has bilateral proptosis (eyes protruding out) with lashes poking into eye (secondary epiblepharon). He has thyroid dysfunction.

Pre op and treatment: This boy has bilateral proptosis (eyes protruding out) with lashes poking into eye (secondary epiblepharon). He has thyroid dysfunction.

Post op: This boy has a biopsy in the orbit as there are some some tissue density in the orbit. The pathology showed inflammation. With the biopsy and steroid, he showed remarkable improvement.

Post op: This boy has a biopsy in the orbit as there are some some tissue density in the orbit. The pathology showed inflammation. With the biopsy and steroid, he showed remarkable improvement.

Moderate thyroid eye disease with downward displacement of left eye despite oral steroid treatment.

Moderate thyroid eye disease with downward displacement of left eye despite oral steroid treatment.

Post local treatment : the inferior displacement of eye has improved significantly. Unfortunately, patient decline treatment and hence still some downward deviation.

Post local treatment : the inferior displacement of eye has improved significantly. Unfortunately, patient decline treatment and hence still some downward deviation.

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