Wednesday, February 28, 2024

Thyroid Eye Disease Double Vision Treatment

Thyroid Eye Disease Surgery Treatment

THYROID THURSDAY – Surgery for Double Vision, Part 1

We can treat mild cases of Graves orbitopathy with medications, such as lubricating eye drops and steroids. Other options include surgery. The UTED team at the University of Utah will work with you to determine if you need any of these surgeries.

Each of these surgeries addresses different aspects of Graves orbitopathy.

Eyelid surgery can improve both how your eyelids look and how they function.

What Is Thyroid Eye Disease

Thyroid eye disease is a rare autoimmune condition in which the bodys immune system attacks the cells in the muscles and fatty tissues around the eyes. It is also sometimes called thyroid associated orbitopathy or Graves ophthalmopathy.

Thyroid eye disease is linked to preexisting thyroid conditions, but it is not a complication of thyroid disease. It often stabilizes after a few months and never gets worse. The condition can be treated by managing its symptoms and living a healthy lifestyle. If the condition becomes severe, aggressive treatments like radiation or surgery may be needed to keep it under control.

In The Second Installment Of This Two

Management of thyroid eye disease has shifted dramatically from conservative measuresobservation and surgeryto 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. Treatments for active-phase disease have also multiplied, which significantly affects quality of life for these afflicted patients.

Last month, in part one of this two-part series on TED, I discussed the keys to diagnosing TED. Here, in part two, Ill discuss the best techniques for managing patients with TED.

Figure. 1. Eyelid swelling and ocular redness in a patient with thyroid eye disease . Improvement in redness and swelling after orbital steroid injection .

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.

Steroids. Steroids are excellent for reducing symptoms in TED, but arent disease-modifying rather, they improve soft-tissue symptoms in the active phase until the body can pass into the stable phase of the disease.

Figure 2. Bilateral proptosis in a patient with thyroid eye disease . Dramatic reduction in proptosis seen after orbital decompression surgery .

Figure 4. Eyelid retraction with improvement in upper lid position after eyelid retraction surgery .

Surgical Therapies

Future Directions

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What Are Treatments For Thyroid Eye Disease

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Thyroid eye disease is a progressive condition. This means that it gets worse over time. There are 2 phases of TED: an active phase and an inactive phase. Each phase is different. Treatment goals for each phase are also different.1

The goal of treatment in the active phase is to reduce inflammation. Treatment goals in the inactive phase focus on repairing damage of tissue.1,2

It is possible for TED to flare after the inactive phase, causing active symptoms to reappear. TED is a rare condition and can cause serious vision issues if left untreated.1

Seeing a TED specialist is important. TED specialists are eye doctors who specialize in diagnosing and treating the disease. These doctors will recommend the best treatment for you, depending on your symptoms and history.2

The treatments most commonly used for the different phases of TED include:1,3

  • Supportive treatments

What Causes Thyroid Eye Disease

Thyroid Eye Disease

TED is usually associated with systemic 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?

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How Is Graves Disease Diagnosed

If you believe you have Graves disease, you should seek medical attention. Healthcare professionals can assess your case based on your symptoms and findings during a physical examination. Approximately one out of every three people with the condition will show signs of Graves ophthalmopathy.

To diagnose the disease, doctors may perform one or multiple blood tests. They may also check for an enlarged thyroid and ask about a family history of thyroid or autoimmune problems.

If clinical doubts remain, doctors may follow up with further blood tests or perform imaging scans like magnetic resonance imaging . These imaging tests may use small yet safe doses of radioactive iodine to see iodine uptake by the thyroid.

Thyroid Eye Disease Medical Treatment

The U.S. Food and Drug Administration recently approved a medication called Tepezza to treat adults with thyroid eye disease. The move represents the first drug approved for the treatment of thyroid eye disease.

How it Works:

  • Tepezza is a specialized monoclonal antibody that specifically targets the insulin-like growth factor-1 receptor and thyroid-stimulating hormone receptor to prevent orbital fibroblasts from causing inflammation and swelling in the eye socket.


  • 8 out of 10 people had less eye bulging in as few as six weeks.
  • 7 out of 10 had improvement in double vision while 5-10 people had a complete resolution of double vision.
  • 2 out of 3 people had resolution of pain, redness, and swelling as soon as six weeks, and improvement continued throughout their treatment with Tepezza.
  • Some side effects of Tepezza can be muscle spasms, nausea, alopecia, diarrhea, fatigue, hyperglycemia, hearing impairment, dysgeusia, headache, and dry skin.

We can treat mild cases of Graves orbitopathy with medications, such as lubricating eye drops and steroids.

There also are other medical treatments that can be tried to help improve the quality of life and symptoms.

Patients can also control the severity of TED symptoms by trying these things:

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Evaluation And Diagnosis Of Thyroid Eye Disease

Thyroid eye disease is typically diagnosed based on medical history and presenting symptoms.

If a patient with some form of thyroid disease experiences eye changes such as lid retraction, bulging eyes, redness, tearing, double vision, or loss of vision, their doctor may refer them to an ophthalmologist to be evaluated for thyroid eye disease.

Blood tests may be done to check thyroid levels. Imaging tests, such as a CT scan or MRI of the orbits, can be used to evaluate the extent of inflammation.

What Is The Outlook For Thyroid Eye Disease

Treatment options for Thyroid Eye or Graves Disease | Ohio State Medical Center

Thyroid eye disease is a temporary but drawn-out illness which fades away by itself. The inflamed period tends to last months to years , after which there is a healing response. For most people the condition will be mild, needing lubricants and regular assessments only. For those with more severe disease, the outlook depends on how early it is diagnosed and how intensive the treatment is. About 1 in 4 people with severe disease will end up with reduced eyesight.

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Simple Steps To Be Taken At Home Along With Medical Treatment In The Active Phase Are

  • Head elevation while sleeping
  • Use sun glasses in sunlight
  • Diabetes control
  • Daily vision checks at home by closing one eye at a time so that decreased vision in one eye can be detected early.
  • Look for colour desaturation at home while watching TV by closing one eye.
  • The staring appearance can be corrected temporarily with botox and fillers.
  • Quite often there are cosmetic problems like prominence and bulging of the eyes, staring appearance, squinting , puffiness of eyelids in the inactive phase .

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What Causes Double Vision

Depending on the type of double vision you have, there are a variety of causes. Here are the causes of double vision based on each type of diplopia.

Binocular double vision causes

  • Abnormality in the lens of the eye
  • Abnormality in the vitreous humor
  • Abnormality in the aqueous humor

Physiological double vision causes

Double vision can also be temporary. Common causes of temporary double vision include:

  • Alcohol consumption

The Thyroid Gland And Important Terms

Thyroid eye disease

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 or underactive . 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 bodys 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. The cause of autoimmune diseases is largely unknown.

The Thyroid Gland

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    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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    New Study: Breakthrough Drug Reduces Graves Eye Disease Symptoms

    A clinical trial led by the University of Michigan Kellogg Eye Center offers hope for those with moderate to severe active TED. Patients had a significant reduction in the severity of symptoms after treatment with teprotumumab, a study drug the Food and Drug Administration designated a breakthrough therapy. Learn more about the results of this clinical trial.

    Other Types Of Treatment

    Treating Thyroid Eye Disease From Home

    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.

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    Therapeutic Efficacy Of Teprotumumab

    The efficacy of teprotumumab was evaluated in two randomized, double-masked, placebo-controlled, multicentre trials in patients with active, moderate-to-severe TED: the phase III OPTIC trial and an earlier phase II trial . Efficacy data are also available from the open-label extension of OPTIC , which enrolled patients from OPTIC who did not achieve a proptosis response . Early real-world experience with teprotumumab in the treatment of TED has also been reported .

    What Is Contingency Fee

    A contingency fee agreement is a legal fee agreement where a client only pays an attorney if the attorney is successful in recovering compensation on the clients behalf. Under a contingency fee agreement, an attorney works on a case for a fixed percentage of any recovery paid to the client. The contingency fee percentage can vary from state to state and by the complexity of the legal matter but is typically 33% to 40% of the compensation received by the client. Under a contingency fee agreement, the client does not pay an attorney any up-front or on-going legal fees, and the client is not responsible for any legal fees if the attorney does not obtain compensation for the client.

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    Early Signs And Symptoms Of Ted May Include12


    Proptosis is caused by expansion of the orbital fat and muscles behind the eyes. The lacrimal glands are frequently involved and enlarged, causing bulging of the eye. Proptosis is one of the most common symptoms of TED.3


    Diplopia is caused by swelling and inflammation of the extraocular muscles and typically restricts the movement of the eye, causing double vision. The most frequently involved muscle is the inferior rectus.4

    Eyelid retraction

    Upper eyelid retraction develops from levator and Müller muscle inflammation and fibrosis or from levator muscle overaction caused by inferior rectus restriction. Symptomology overlaps between Graves disease and TED. Upper eyelid retraction is one of the most common symptoms of TED.3,4

    Pressure and/or pain behind the eyes

    TED causes an increase in the orbital soft tissue volume, which leads to a higher pressure within the inexpandable bone cavity.3

    Dry eyes and grittiness

    Dry eyes and grittiness are frequently under-recognized signs of TED.6 In a long-term follow-up study in a single US county, 72% of patients with TED said dry eyes were their most frequent source of eye discomfort.7 These symptoms are often misdiagnosed as allergies or conjunctivitis.8

    Redness, swelling, and excessive tearing

    When To See A Doctor


    You should see a doctor anytime you experience new or worsening symptoms that could be related to thyroid eye disease. This is particularly important if you have already been diagnosed with a thyroid condition. This condition can worsen very quickly and may lead to poor outcomes if it is not stabilized with treatment.

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    How To Diagnose Diplopia

    Your doctor will perform a number of physical examination tests that will identify any potential physical abnormality causing diplopia. However, the most effective tool will be the information you provide during the history portion of the examination. Once the symptoms of double vision have been presented to the doctor, they will most likely ask you a series of related questions that will narrow down the causes. These questions may include:

    • When did the double vision start?
    • Have you hit your head, fallen, or been unconscious?
    • Were you in a car accident?
    • Is the double vision worse at the end of the day or when youre tired?
    • Have you had any other symptoms besides double vision?
    • Do you tend to tilt your head to one side when looking at objects?

    Additional eye related examination tests will then take place to better understand your presenting symptoms. This will often include looking at distance objects, assessing field of vision, and covering one eye while looking at objects.

    Early Thyroid Eye Disease Treatment Can Help Prevent Serious Eye Damage

    Thyroid Eye Disease is a serious, vision-threatening condition that can get worse over time, if left untreated. The longer that TED goes untreated, the more likely it is for serious damage to happen to your eyes. The earlier you start treatment for your Thyroid Eye Disease, the better. Read on to learn about your TED treatment options.

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