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Thyroid Eye Disease Surgery

What is thyroid eye disease?

Thyroid eye disease is most commonly associated with a disorder of the thyroid gland – hyperthyroidism and can also be known as Graves’ ophthalmopathy/orbitopathy and Thyroid Associated Ophthalmopathy (TAO). The effects of thyroid eye disease can include local inflammation, swelling and fibrosis of the eye structures, including the fat around the eye and in the muscles which moves the eyes. It can sometimes occur in patients who have no thyroid dysfunction, or patients who have thyroid hypo-function. Most patients with thyroid problems do not develop an ophthalmopathy, or, if they do, it is only mild. A small proportion of patients who develop thyroid eye disease, may require treatment.

Thyroid eye disease has recognised stages. There is an early active phase, in which inflammation is present. This will usually last between 3 and 12 months before beginning to stabilise, becoming inactive. During the active phase maximal symptoms will develop, with eyelid retraction, eye protrusion and possible double vision and redness. If the active thyroid eye disease is treated early enough, it may be possible to reduce the severity of the disease and need for surgery.

What happens at surgery?

In the active phase, if the vision is threatened/affected, or there is severe exposure (dryness) of the front of the eye, urgent surgery may be required. Some younger patients who have healthy, tight tissue may experience reduced vision from optic nerve compression, but will not have particularly protruding eyes. In such cases, urgent medical treatment, and/or decompression will need to be carried out in order to preserve visual function.

Once the patient has overcome the acute phase, which may take 12 to 24 months, the oculoplastic surgeon will carry out rehabilitative surgery. Several operations are available for rehabilitation of thyroid eye disease:

Orbital Decompression

Orbital decompression is surgery to reduce the protrusion, or proptosis, of the eyes making the orbits larger internally by creating openings into the adjacent air cells (air sinuses). This is done by an oculoplastic orbital surgeon through a small eyelid incision at the outer corner of the eye. Most of the incision will be hidden on the inside of the lower eyelid. A balanced decompression is aimed for, in which the orbit is widened horizontally, thus reducing the risk of double vision. This operation is also carried out during the acute phase if there is an optic nerve compression, in which the pressure, or tension, on the nerve is reduced by increasing the internal size of the orbit by operating surgically on the bony walls.

Eye Muscle Surgery

If there is eye muscle scarring resulting in double vision this can be treated with prisms incorporated into glasses. If the double vision cannot be easily corrected with prisms, eye muscle surgery is necessary. Eye muscle surgery is performed once the amount of double vision is stable. The aim of surgery is to restore a good field of binocular vision i.e. When using both eyes there is no or reduced double vision when looking straight ahead and reading.

Squint surgery may not completely remove all double vision and the patient may still notice some double vision in extremes of gaze. The surgery is usually carried out under general anaesthetic and may involve an adjustable stitch on the eye muscle. To give the best possible single vision, this can then be locally adjusted once the patient is awake, just a few hours after surgery.

Eyelid Retraction

Eyelid surgery can be carried out to correct the eyelid position if the upper eyelids are too high, or the lower eyelids too low. This will reduce the staring appearance, allowing for improved eyelid closure and less exposure (dryness). During surgery, the upper eyelid is lowered, or the lower eyelid raised. In raising the lower eyelid, a small spacer, using tissue from the roof of the patient’s mouth, is sometimes necessary.

Further Eyelid Surgery – Blepharoplasty & Peri-Ocular Surgery.

Thyroid Orbitopathy can result in coarsening and thickening of periocular structures. This appearance can be improved utilising several techniques:

  • Botulinum Toxin A to reduce exaggerated frowning
  • Dermal filler to deep folds
  • Upper eyelid Blepharoplasty (removal of excess skin, fat and debulking of sub brow tissue)
  • Lower eyelid Blepharoplasty

What are the signs and symptoms of thyroid eye disease?

  • Staring appearance with upper and lower eyelid retraction, resulting in more white of the eye being apparent.
  • Bulging or proptotic eyes, where the eyes protrude forwards and look very big.
  • Peri-ocular swelling, with puffiness of the eyelids, sub-brow area and peri-ocular region.
  • Orbital ache, particularly on eye movements.
  • Double vision (diplopia), either looking straight ahead, or on extremes of gaze.
  • Bloodshot appearance to the eyes associated with one or more of the above.
  • Reduced vision, particularly for colour vision, if the optic nerve is compressed.

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Reba Cosmetic Clinic

Spire Cheshire Hospital, Stretton, Warrington, Cheshire WA4 4LU

Appointments call: 01925 215068