Thyroid Eye Disease (TED)
Thyroid Associated
Orbitopathy(TAO)
Dysthyroid Eye Disease
These are the
different names for the same condition
Patients with past/present or future
thyroid gland dysfunction might develop an autoimmune disorder
involving the muscles and fatty tissues in the eye socket.
However, there is a small group of patients (10%) with thyroid
eye disease that never develop thyroid gland problems.
Though related, Thyroid Orbitopathy runs an autonomous course
independent from the thyroid gland itself. Therefore in this
respect it is different from “poppy” eyes seen in an overactive
thyroid that settles down as soon as the patient is treated with
medication.
Females, particularly smokers, and with family history of
thyroid dysfunction are more likely to develop Thyroid
Ophthalmopathy.
What are the signs:
Eyelid puffing and swelling.
Watery eyes.
Dry eyes.
Double vision.
Starey eyes.
Pain on eye movement.
Rarely visual disturbance.
How is it treated:
Patients are seen in a dedicated thyroid eye clinic where
objective measurement of signs and symptoms are made according
to an international scoring system. Often an orbital scan is
requested.
If signs and symptoms, as well as the scan suggest an active
disease, patients are treated with a short course of oral
steroids or three days of pulsed intravenous (IV) steroids.
Local steroids can be injected around the eye as well.
This mode of delivery of steroids is safe, but can briefly cause
the pressure in the eye to increase requiring monitoring and
treatment.
In severe cases other immunosuppression
drugs such as Azathioprine are prescribed.
Rarely is the swelling in the eye socket as such that the optic
nerve is compromised. Patients will notice fluctuation of
vision or frank loss of vision.
In this instance, patients would require admission and a high
dose of steroids.
This is an emergency and patients should report immediately
to Miss Khooshabeh’s secretary on 01494 425890.
To prevent side effects arising from long term use steroid
treatment is followed by a low dose of orbital radiotherapy
given daily for two weeks as an outpatient. 14% of patients
might experience hair loss at the temples and a brief increase
in soft tissue swelling during the radiotherapy.
Steroid/radiotherapy treatment has about 60-65% success rate in
relieving the eye symptoms. The relief is more pronounced in
soft tissue swelling and watery eyes than in double vision and
proptosis.
Every effort will be made by the endocrinologist to make sure
the patient’s thyroid function is normal and this would be
achieved by medication, surgery or radioactive iodine.
Thyroid eye disease can become worse particularly in female
smokers following radioactive iodine. This is less likely if the
patient is treated with oral steroids at the same time.
Orbital radiotherapy is used with caution in diabetic patients
particularly those with diabetic retinopathy as it can worsen
the retinal changes caused by diabetes.
It is also avoided in young patients due to theoretical
increased risk of late tumours developing. However, to date no
such case has been reported.
However the majority of thyroid eye disease patients have a mild
disease and do not require the above treatment protocol.
Stopping smoking is the single most effective measure to improve
eye symptoms. Lubricant eye ointment at bed time and artificial
eye drops during the day can help. Cool compresses and head
elevation whilst sleeping helps reduce eye lid swelling.
Patients attend the eye clinic for review of their condition
every three months until their eye and thyroid is stable.
Thyroid eye disease is a self-limiting disorder lasting about
three years.
Rarely however might one see a reactivation many years later.
When is eye surgery offered:
Surgery is generally reserved for quiescent (inactive) disease.
Surgery is not offered until eye signs and the thyroid function
test have been normal for at least six months.
The majority of patients do not require surgery. However,
options of orbital decompression/muscle and/or eyelid surgery
would be discussed at this stage.
Surgical procedures for thyroid Eye disease
Orbital decompression:
Here two or sometimes three bony walls of
the orbit are removed to allow the orbital content to expand
into the adjacent sinuses. This will reduce the pressure effect
on vital structures such as the optic nerve, muscles, vessels
and nerves.
Orbital decompression is also used to
improve cosmesis and it is available under the NHS.
Risks of orbital decompression:
Double Vision.
Reduced vision.
Muscle surgery (squint surgery):
This is usually undertaken when deviation
of the eye has remained stable for at least six months.
Whenever possible double vision is corrected by prisms
incorporated into the glasses.
Eyelid retraction:
One of the most annoying signs of thyroid
eye disease is the starey appearance caused by the retraction of
the upper and lower lids. It is possible to weaken the muscle
in the upper lid to give a more natural appearance. The
operation is usually performed under local anaesthetic. It is
also possible to raise the lower lid often a small spacer is
required to achieve this. The lining of the roof of mouth
provides a good spacer for this purpose.
Blepharoplasty:
Infiltration of the eyelids by
inflammatory cells gives rise to puffy eyelids. The appearance
of this can be reduced by removal of some fatty tissue in the
upper and lower lid. A small amount of skin is also removed.
To improve cosmesis this operation is currently allowed under
the NHS.
Botox:
Botox is used early in the disease to drop
the upper lid when other more invasive procedures can not be
undertaken as the patient is still in the active stage. A small
amount of botox is injected into the upper lid of the patient
after a few drops of local anaesthetic. A few units of botox
are also injected in between the eyebrows to reduce the angry
appearance. The effect of botox, as well as its complications
(double vision/droopy eyelid), is temporary. Often the
injection has to be repeated after two to three months.
This treatment is available under the NHS.
Thyroid Eye Disease (TED) Association
This organization provides information and support to patients
with thyroid eye disease.
www.thyroid-fed.orgmembers/TED
TEL: 01797-222-338 EMAIL:
tedassn@eclipse.co.uk
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