Thyroid Eye
Disease (Philadelphia)

When thyroid antibodies are incubated with muscles of the human body, other skeletal muscles of the human body experience binding; when incubated with muscles around the eye, selective swelling occurs.

Abnormal deposits of immune complexes cause the orbital fibroblast (a cell that produces collagen and proteins, among other things) to produce an abnormal glycosaminoglycan (a protein sugar) that causes swelling in the orbit (the eye socket).

Symptoms that are generally considered suggestive of thyroid eye disease are eyelid retraction—this is a pulling upwards of the upper and lower eyelids—and swelling of the globe. The eye actually appears to bulge, and puffiness develops around the eyes because of the deposition of fat. Often patients will present with eyelid retraction thinking that they have skin excess and fat excess, presenting for cosmetic surgery when actually they have thyroid eye disease. They sometimes develop festoons—areas of swelling in the cheeks, and are sometimes asymptomatic. Patients will often present to an ophthalmologist with dry eyes and irritation because the conjunctiva (the skin of the eyeball) can become red and irritated, and the eyes themselves can dry out because tear secretion changes in thyroid eye disease. Patients who have severe thyroid disease develop double vision. The double vision and changes in their vision, including color vision, formed vision, and loss of vision, is possible in a small group of patients. Patients with thyroid disease can also have increased pressure, especially on upgaze that makes them suspect for glaucoma.

Abnormalities of the thyroid are said to occur in 5 percent of women over the age of 40. Abnormalities of the orbit and eyelids occur in a much smaller group of patients.

When they occur, and symptoms include protrusion of the eye, these symptoms will spontaneously improve over a period of follow-up if this disease runs its course. However, in a subgroup of patients, issues such as double vision and blindness can occur, and it is best to be followed by an ophthalmologist or an oculoplastic surgeon in the course of these changes if they occur. In the presence of optic nerve involvement causing visual obstruction, treatment should not be delayed because there is the possibility of irreversible visual loss.

Unfortunately, women are struck by this disease, usually in the prime of their lives, with a greater frequency than men, but it can occur at any age. The disease is potentially deforming, and it is heartbreaking to see patients go through this period and only be told that they need to be patient and that things will improve over time. Smoking exacerbates this disease, and it is absolutely essential and definitely recommended that anyone with thyroid disease cease smoking. Selenium in small doses—the amount used in most multivitamins—has been found to be useful in lessening the course of ophthalmopathy, so vitamin supplementation may be worthwhile.

In situations of globe prominence and in the subgroup of patients that have no demonstrable abnormality by blood testing, we often obtain ultrasonography. Ultrasonography can show enlarged muscles and is the most sensitive way to test for thyroid ophthalmopathy.

Initially, stabilization of thyroid function is necessary. Occasionally, removal of the thyroid or radioactive iodine ablation of the thyroid is recommended. If this latter approach is chosen, oral steroids should be administered by the radiation oncologist to protect against the liberation of antibodies that occur with radiation; studies suggest that steroids may help reduce the incidence of Grave’s ophthalmopathy after radiation of the thyroid.

In certain circumstances, radiation of the orbits themselves is recommended. Surgery is a mainstay for optic nerve decompression and is being performed with increasing frequency to treat dry eyes and the overall cosmetic disfigurement of the disease. It can be accomplished in conjunction with other aesthetic procedures around the eyelids to improve function and appearance.

High-dose intravenous steroids and chronic steroids have been advocated by some to lessen the severity of ophthalmopathy.

Tepezza was released in 2019 after Phase III clinical trials showed it to be incredibly effective for treating the early inflammatory phases of thyroid eye disease. Tepezza is given IV in a total of eight doses every three weeks and has been shown to improve the symptoms of thyroid disease, including redness, inflammation, double vision, and the bulging associated with TED. Tepezza works by blocking the receptors that bind to the muscles, preventing the muscle and fat tissue from swelling in the early phases of the disease. Studies are underway to determine whether it may be beneficial in more chronic cases.

You are best assessed by an oculoplastic surgeon or a neuro-ophthalmologist. These doctors most commonly are the ones that treat these conditions.

We have been performing oculoplastic surgery and have training in cosmetic surgery, oculoplastic surgery, and orbital disease, and have been involved in the care of thyroid eye patients for more than 25 years. A consultation either via telehealth or in person may be the best way to determine if our practice is right for you.

Orbital decompression is a procedure performed under general anesthesia, usually on an outpatient basis. No dressings or patches are employed. One eye or both eyes can be operated simultaneously. The surgery is done in conjunction with an orbital otolaryngologist specialist in endoscopic surgery of the orbit. Eye muscle surgery (strabismus surgery) can be accomplished to straighten eyes that are not aligned. Eyelid surgery can be performed to relieve the puffiness, lessen eyelid retraction, and improve the overall look. These are all outpatient surgeries.

We have pioneered orbital advancement/decompression procedures for thyroid eye disease: the eye socket is enlarged to accommodate the bulging eye. We perform endoscopic orbital decompression through small, easily hidden incisions in the upper eyelid and inside the nose that can reverse the visual loss caused by the thyroid optic neuropathy. We also employ the endoscopic small incision decompression approach to reduce the swelling of the eyes and improve the overall cosmetic result.

The risks of this surgery are not inconsequential and are best discussed at the time of your visit. If forced to do the surgery, the risks certainly are outweighed by the benefits. In a situation where the surgery is being performed for cosmetic purposes, the risks include blindness and double vision. These conditions are fortunately exceedingly rare. Blindness caused by orbital decompression has not been observed in our practice but is well-documented and must be taken into account by the patient. When possible, we advocate other approaches that have less risk associated with them.

Once thyroid eye disease is diagnosed, recommendations are made regarding the treatment of dry eye and all symptoms. Vitamin supplementation therapy and avoidance of smoking are encouraged. We work with several endocrinologists to ensure that your endocrine function is regulated. If you are a candidate for Tepezza treatment, we will refer you to the appropriate IV infusion center. If possible, we like to delay surgery until the ophthalmopathy stabilizes. At that point, surgery to reduce swelling and improve retraction, puffiness, and overall appearance can be performed more safely.

The postoperative care for the procedure is easily performed by a family member or a friend and involves the use of ice to minimize swelling and redness and pain therapy. No patches are employed after any eye surgery related to the thyroid. Occasionally, eyelid surgery alone can be performed to enhance the appearance and to obtain coverage of the globes and also improve appearance. This surgery is also done on an outpatient basis and does not have the same associated risks.