Pearls And Other Issues
A high index of suspicion is essential for patients with the classic symptoms of thyroid eye disease, with no history of thyroid disorders or a euthyroid status at presentation. An endocrine workup and orbital imaging are essential for a definite diagnosis in the absence of classical clinical presentation.
The management includes strict maintenance of euthyroid status, cessation of smoking, adequate lubrication, adequate control of the IOP, and monitoring of disease progression as per the CAS / VISA scoring systems at regular follow-ups. Any sign of progression to active disease or sight-threatening disease warrants urgent management.
Enhancing Healthcare Team Outcomes
Thyroid eye disease cases require a multi-specialty effort for early diagnosis and timely management. Physicians and endocrinologists are the primary contacts for thyroid disorder cases. All predisposed patients should undergo regular eye checkups. Long-term sustenance of euthyroid status is the foremost pillar for TED prevention.
Appropriate control of smoking and nicotine addiction is necessary with the involvement of psychiatrists, de-addiction clinics, anonymous support groups, counseling, and patient deterrence. The sight-threatening disease and cosmetic disfigurement are also a source of anxiety for the patients. Trained professionals are necessary to deal with psychosocial issues.
Ophthalmologists and oculoplastic personnel play an essential role in the long-term follow-up, medical, and surgical management of TED cases. Visual and cosmetic rehabilitation are important end-points of TED management.
Signs And Symptoms Of Graves’ Eye Disease
In Graves eye disease the tissue around the eye is attacked, and the result is inflammation and swelling, causing:
- Redness and pain
- Dry eye and irritation, occurring when the eyelids cannot close completely over bulging eyes
Progressive swelling may cause:
- Increased pressure inside the eye socket
- Pressure-pain or deep headache, which worsens with eye movements
The muscles around the eye are particularly susceptible to the attack of lymphocytes. As they tighten and lose their ability to stretch, these symptoms can occur:
- The eye is pushed forward in its socket causing a staring appearance
- Restriction of the eyes normal movements, resulting in double vision
As symptoms build, many patients fear they will lose their vision. Fortunately, patients almost never go blind from Graves eye disease.
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Postoperative And Rehabilitation Care
Cosmetic rehabilitation is essential in TED management. Asymmetrical proptosis is common during inactive disease. A graded surgical orbital decompression helps achieve a cosmetically symmetrical look.
The surgical plan is customized depending on the amount of proptosis correction, the pattern of strabismus, and the orbital anatomy. The restricted EOM is recessed to achieve orthophoria in the primary gaze. The final correction for the lid retraction is planned at least six months after the strabismus surgery. Blepharotomy, blepahromyotomy, levator recession, and spacer grafts are the common strategies for lid retraction correction.
What Causes Thyroid Eye Disease
Thyroid eye disease is often associated with Graves disease, an autoimmune disease causing hyperthyroidism, but not everyone with TED has Graves disease. Still, the majority of people who have TED have Graves disease, or another thyroid condition, such as an underactive thyroid due to a different autoimmune thyroid disorder called Hashimoto thyroiditis.
It is a common misconception that TED is caused by hyperthyroidism , most commonly Graves Disease, even to the point where TED is sometimes called, Graves Eye Disease, explainsHoward Krauss, MD, surgical neuro-ophthalmologist and director of Pacific Neuroscience Institutes Eye, Ear and Skull Base Center. The association of these two autoimmune diseases is so prevalent that it is more likely than not that having one of these conditions is predictive that the other is likely, although the two diseases may occur years apart.
Like Graves disease, TED is an autoimmune disease. In the case of TED, the body mistakes the tissues near the eye as foreign bodies and attacks them. The mechanism that causes TED to develop isnt fully understood, but researchers believe that proteins in your eye tissue that are similar to proteins from your thyroid gland are mistakenly attacked by antibodies, causing inflammatory symptoms.
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How Do You Treat Hyperthyroidism In People With Ted
Overactive thyroid and TED often occur within one year of each other. But they can also form within decades of each other.
In 10% of people with TED, either their thyroid levels stay normal, or they get autoimmune hypothyroidism.
Our treatment goal is to get your thyroid function back to normal.
We don’t advise radioactive iodine to treat moderate-to-severe TED, as it can worsen eye disease.
Treatments for people with moderate-to-severe or sight-threatening eye disease are antithyroid drugs or thyroid surgery.
We suggest surgery to remove part or all of the thyroid gland in people who have:
- Adverse reactions to antithyroid drugs.
- Enlarged thyroid glands.
- Plans to conceive in the near future.
What Tests Will Be Done To Diagnose Thyroid Eye Disease
A healthcare provider will be able to diagnose thyroid eye disease by doing a physical eye exam. They will be able to examine both your eyelids and your eyes.
If your healthcare provider thinks that you have thyroid eye disease, theyll order blood tests to check if your thyroid hormone levels and antibodies are too high or too low.
Other tests your provider may request include:
- Ultrasound of the eyes.
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Thyroid Eye Disease Center
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The eye changes associated with thyroid disease are referred to as Thyroid Eye Disease . Your doctor may also use the term Thyroid Associated Orbitopathy . 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 , 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.
Are There Any Complications From Thyroid Eye Disease
Most people do not develop permanent complications. However, where treatment is delayed or where the thyroid eye disease has been severe, there can be lasting effects. They are also more likely in older people, in those who smoke and in people with diabetes. Possible complications include:
Complications from the disease
- Damage to the clear window of the eye .
- Permanent squint or double vision .
- Damage to the nerve of the eye, resulting in poor vision or colour appreciation.
- Altered appearance .
Complications from treatment
- Side-effects from the immunosuppressive medicines.
- Side-effects from the surgery:
- New double vision .
- Loss of vision .
- There are some other very rare complications that your surgeon will talk you through.
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Other Types Of Treatment
If you develop double vision , you may be referred to a specialist health professional who manages problems with eye muscles . They may give you modified glasses that block off vision from one eye or put a special cover, called a prism, over one side to stop the diplopia.
Treatment using radiation may be used in some places on some people. The aim is to reduce the swelling in the eye. It is used alongside other forms of treatment.
A number of new treatments are being investigated.
Your doctors will also treat any abnormality of thyroid function with antithyroid medicines. This is usually with tablets but may also include radioactive iodine or, uncommonly, surgery to the thyroid gland. We know that good control of the thyroid function helps lessen the severity of thyroid eye disease. See the separate leaflet called Antithyroid Medicines.
Thyroid Health Blog: Keeping An Eye Out For Thyroid Eye Disease
Home » Thyroid Health Blog: Keeping an Eye Out for Thyroid Eye Disease
Keeping an Eye Out for Thyroid Eye Disease
Matthew Ettleson, MDMarch 16, 2021
The illustrative example of proptosis may be one of the more memorable images in the medical school textbook, but often the more subtle signs and symptoms of thyroid eye disease can be overlooked. While severe thyroid eye disease is uncommon, up to 40% of patients with Graves disease have some signs or symptoms of thyroid eye disease . Most patients with mild eye disease have stable symptoms, but those that develop moderate-to-severe disease may benefit from more aggressive therapies, including glucocorticoids and anti-insulin-like growth factor-1 receptor therapy.
The diagnosis of thyroid eye disease relies on a focused history and exam of the eyes. Patients may complain of dry eyes or grittiness, excessive tearing, pain with eye movements and blurry or double vision. Patients may present classically with proptosis and lid retraction, but also redness and swelling of the eye lids or conjunctiva may be present. If several of these findings are present, it suggests the patient has active eye disease and thus may be more responsive to medical therapy. Any concern for visual impairment should prompt urgent evaluation by an endocrinologist and ophthalmologist for a more detailed assessment.
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How Is Graves’ Disease Treated
The treatment of hyperthyroidism is described in detail in the Hyperthyroidism brochure. All hyperthyroid patients should be initially treated with beta-blockers. Treatment options to control Graves disease hyperthyroidism include antithyroid drugs , radioactive iodine and surgery.
Antithyroid medications are typically preferred in patients who have a high likelihood of remission . These medications do not cure Graves hyperthyroidism, but when given in adequate doses are effective in controlling the hyperthyroidism.
If methimazole is chosen, it can be continued for 12-18 months and then discontinued if TSH and TRAb levels are normal at that time. If TRAb levels remain elevated, the chances of remission are much lower and prolonging treatment with antithyroid drugs is safe and may increase chances of remission. Long term treatment of hyperthyroidism with antithyroid drugs may be considered in selected cases.
If your hyperthyroidism due to Graves disease persists after 6 months, then your doctor may recommend definitive treatment with either radioactive iodine or surgery.
If surgery is selected as the treatment modality, the surgery should be performed by a skilled surgeon with expertise in thyroid surgery to reduce the risk of complications.
What Are The Treatments For Thyroid Eye Disease
There are three main ways to treat the double vision that is caused by Thyroid Eye Disease. Prisms can be used with eyeglasses to try to reduce double vision. Patching one eye will eliminate double vision, but this is not a satisfactory solution for many patients. Finally, misalignment of the eyes can often be improved with surgery. In order to maximize the chance that surgery will successfully realign the eyes, typically the doctor will recommend waiting until the amount of misalignment has remained stable for approximately six months.
It is important to use lubricating eye drops and ointments to prevent dryness and injury to the surface of the eye. Other medications have limited benefits in treating Thyroid Eye Disease. One clinical study found that selenium improved many symptoms when the condition is mild. Corticosteroids can occasionally improve eye movements. However, for most patients there are no convincing long-term benefits from this medication.
When necessary, an additional operation can be performed to relieve severe eye bulging by making more space in the orbit. In addition, surgery can be done to correct the position of the eyelid, which is an important aspect of keeping the eye properly lubricated. Radiation therapy is used when sight is threatened in severe cases of Thyroid Eye Disease. Visual loss can occur when the optic nerve is compressed by swollen, thickened eye muscles.
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Deterrence And Patient Education
All patients with thyroid disorders should be routinely screened for early signs of thyroid eye disease. Regular follow-up of asymptomatic GD and mild TED cases can help prompt diagnosis and management of sight-threatening complications. The patients should be explained the early signs of DON – altered color vision, diminished contrast sensitivity, decreased field of vision, and decreased visual acuity.
Are There Any Side
Long-term treatment with steroids used in severe cases of thyroid eye disease can cause side-effects such as weight gain, diabetes and osteoporosis .
Surgery for cosmetic reasons should be carried out after the inflammation has died down in order to avoid repeated operations. There are general risks associated with surgery and anaesthesia, which should be explained by the surgeon and/or anaesthetist.
Antithyroid tablets can very rarely suppress the production of white blood cells, making the individual more open to infections. Anyone who experiences a sore throat, mouth ulcers or a high temperature whilst taking the tablets should seek medical attention immediately.
Radioiodine therapy used to treat an overactive thyroid gland can worsen thyroid eye disease so this should be avoided while the eyes are inflamed. Radioiodine is therefore only used in mild eye disease if felt necessary and is usually combined with steroid treatment to minimise the risk.
Patients should discuss any concerns with their doctor in case steroids need to be given before or after treatment.
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Why A Multidisciplinary Ted Clinic
When people who have TED get care at a multidisciplinary thyroid eye clinic, they have better outcomes than those who go elsewhere.
At UPMC’s clinic, you’ll see both an ophthalmologist and endocrinologist skilled in assessing and treating TED.
Endocrine surgery, ENT, and other specialists are also part of the team and provide consults when needed.
What Causes Graves’ Disease
Graves disease is triggered by a process in the bodys immune system, which normally protects us from foreign invaders such as bacteria and viruses. The immune system destroys foreign invaders with substances called antibodies produced by blood cells known as lymphocytes. Sometimes the immune system can be tricked into making antibodies that cross-react with proteins on our own cells. In many cases these antibodies can cause destruction of those cells. In Graves disease these antibodies or thyroid stimulating immunoglobulins do the opposite they cause the cells to work overtime. The antibodies in Graves disease bind to receptors on the surface of thyroid cells and stimulate those cells to overproduce and release thyroid hormones. This results in an overactive thyroid .
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Clinical Presentation Of Ted
About 90% of patients with TED also have some thyroid dysfunction – usually the thyroid is overactive , but occasionally the thyroid is underactive . Most times, the diagnosis of TED and diagnosis of a thyroid dysfunction occur within the same year. Patients who are diagnosed with TED but have no known thyroid dysfunction should see their primary care physician for an evaluation of their thyroid function.
The disease course for TED involves 2 phases – active and stable. In the active phase there is active swelling and inflammation. This presents as redness in and around the eye, eye pain with or without eye movement, as well as swelling around the eyes and eyelids. The active phase of TED involves a waxing/waning period of these symptoms, and can last months to years. On average, the active phase of TED lasts about 1 year for non-smokers, and 2-3 years for smokers . The active phase of TED spontaneously transitions to the stable phase, but can recur. Active TED has a recurrence rate of about 5-10%, but is less likely to recur after 18 months in the stable phase.
Figure 3. Active vs. Stable TED. Active TED is characterized by signs of inflammation . TED activity waxes and wanes, and usually transitions to stable TED within 1-3 years.
Figure 4. Rundle’s curve. As seen in the representation of TED activity over time in Rundle’s curve, initiating therapy early is crucial to diminish the overall severity of the chronic disease.
Fact: If You Have Ted You Should See An Ophthalmologist Who Has Experience Treating Ted
Thyroid Eye Disease is a unique and rare eye condition, and not all doctors are used to treating it. Thats why its important that you see a doctor who has the right experiencea TED Specialist.
TED Specialists are ophthalmologists who usually have advanced training, such as oculoplastic surgeons, neuro- ophthalmologists, and strabismus surgeons.
While there are about 20,000 eye doctors in the US, most are not used to seeing TED patients. TED Specialists have advanced training in specific types of eye and vision care.
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Thyroid Eye Disease Management
Thyroid eye disease is a self-limiting disease: if left untreated, the inflammation will gradually go by itself. However, the physical changes caused by the swelling may remain. This is because some of the tissues that have been stretched may not always return to their original form. The aim of treatment is mainly to limit inflammation and swelling occurring during the inflamed period and to protect the surface of the eye. There are also treatments for people whose tissues have not been able to return to their original form after the inflammation has settled.
Thyroid eye disease is managed by a specialist eye doctor and the underlying thyroid problem by your own doctor or by a a specialist in the hormone systems of the body .
Treatment Options For Thyroid Eye Disease
The treatment for thyroid eye disease generally focuses on supportive care to manage the symptoms and control the disease. For more severe cases, steroids or surgery may be suggested.
During the active phase of thyroid eye disease, treatment for a mild to average case typically consists of regular observation with a focus on alleviating the symptoms. This may include lubrication of the eyes, sunglasses, cool compresses, a salt-restricted diet, and sleeping with the head elevated.
In more severe cases, oral steroids may be used to help decrease the inflammation. If the inflammation is severe enough to cause loss of vision or decompensation of the cornea, high-dose intravenous steroids and orbital radiotherapy may be used.
If the response is not adequate, urgent surgery may be performed to decompress the orbit and create more space for the enlarged muscles.
During the stable phase, surgery can be performed if needed to decompress the orbits and decrease the amount that the eyes bulge forward, repair eye muscle alignment for patients with double vision, and improve lid positioning.
If a patient smokes, it is strongly encouraged that they stop smoking, as it is the number one risk factor associated with thyroid eye disease.
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