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Thyroid eye disease and Orbital Decompression

ORBITAL SURGERY

What is thyroid eye disease?

Thyroid eye disease, also known as Graves’ Orbitopathy or Graves’ Ophthalmopathy, is an autoimmune disorder that affects the muscles and fat tissue around the eyes in the eye sockets. It can cause the eyelids to become swollen and inflamed, with the eyelids retracting and giving a bulging appearance. The orbital fat around the eye may also expand, leading to further bulging. This together with swelling or scar tissue in the muscles that move the eye can lead to double vision, and in rare cases, the pressure on the optic nerve can cause vision loss, known as optic neuropathy.

What are the symptoms of Graves' eye disease?

Inflammation of the tissues around the eye can lead to a variety of symptoms,

  • Redness of the eyelids and the eye.
  • Pain at rest or on eye movement.
  • Swelling of the eyelids and the eyeball,
  • Bulging of the eyes, dry eye and irritation.
  • Increased pressure within the eye socket.
  • Double vision due to swelling and scarring of the eye muscles.
  • Decreased vision.

Does everyone with graves get bulging eyes?

Approximately 30% of people with Graves disease develop ophthalmopathy, although bulging of the eyes is not a frequent occurrence. Early treatment of Graves’ disease can help to prevent the development of the condition.

How do you treat bulging eyes from Graves' disease?

Mr Ahmad Aziz of his London clinic believes that the best way to prevent bulging eyes is to take preventive measures early on.

  • Ensuring that the thyroid hormone levels are properly balanced with medication.
  • Quitting smoking if applicable.
  • Taking selenium supplements in mild cases.
  • Treating active disease early with corticosteroids
  • Considering autoimmune condition medications if steroids do not help.
  • In more severe cases, radiation therapy or orbital radiotherapy may be considered for those over the age of 30.
  • Avoiding radioactive iodine treatment for Graves’ disease if there are already signs of ophthalmopathy.

Finally, orbital decompression surgery may be considered if there is already bulging, the thyroid is no longer underactive or overactive, and the eyes have been stable for many months.

How do you get thyroid eye disease?

This is an autoimmune disease associated with an imbalance in the hormone levels of the thyroid gland. Since the immune system affects the thyroid gland, it can also affect the eye cavities, activating cells known as Orbital fibroblasts. The disease process is further promoted by smoking and possibly other conditions such as rheumatoid arthritis and diabetes mellitus. The development of inflammation can lead to swelling, redness, pain and visual problems with the eyeball ceasing to maintain its normal position and moving forward, which leads to exophthalmos or bulging.

What is the treatment?

Inflammation usually leads to dry and irritated eyes, which can lead to watery eyes. This can be treated with eye drops such as artificial tears. Data from clinical trials have shown that selenium supplements can have a beneficial effect on the disease process in mild conditions. Stopping smoking is a key factor. The goal of treatment is to prevent severe illness that requires surgery. Surgical options are usually offered as soon as the disease is in the burning stage.

Vision loss is a rare condition associated with the disease and this is a condition that may require emergency orbital decompression. In the burning phase puffiness can be treated with orbital decompression, double vision may be amenable to eye muscle surgery and eyelid retraction can be treated with steroid injections or eyelid surgery.

Is the disease permanent?

The disease rarely remains permanently active and will eventually burn out. The damage caused during the active phase can be permanent and the main goal of treatment is to try to prevent permanent damage and offer treatment options in the burning phase if this happens.

The goal of treatment at this stage is to restore the appearance of the face before getting the disease with various types of surgery tailored to the individual. Surgical options include surgery of the eye socket, eyelids, and eye muscles depending on what is affected and what the patient wants.

Does thyroid eye disease go away?

The disease process will eventually burn out and he aim of treatment is to minimise the risk of severe disease and maintain healthy tissue around the eye muscles and the eye socket.

How long does it take for the disease to burn out?

During the active phase of thyroid eye disease, which can last for up to 18 months or longer, the goal of treatment is to minimize or prevent any disfigurement that can occur. Smoking is a key factor that can make the active phase more severe and last for a longer period of time, increasing the risk of symptoms such as eyelid retraction, scarring of the extraocular muscles causing double vision, orbital inflammation, and fatty tissue accumulation resulting in bulging or proptosis of the eyes. Once the active phase of the disease is over, the disease process will eventually burn out.

What is an orbital decompression?

  • This is a surgical procedure performed under general anesthesia that aims to treat bulging of the eyes. It is a form of reconstructive surgery and increases the orbital volume, most commonly with a bony decompression. In this procedure, parts of the orbital walls that form the eye socket are removed to increase the space within the socket, allowing the orbital contents to rest back in a more natural position.
  • A unilateral wall decompression is where one wall of the socket is decompressed – most commonly the lateral wall or the medial wall. A lateral wall decompression involves an incision at the lateral aspect of the eyelid in the skin crease or the corner of the eyelid (known as the lateral canthus), while a medial wall decompression requires an incision on the inside of the eyelid near the nose behind a bony landmark known as the posterior lacrimal crest.
  • In some cases, a triple wall decompression is used, where the orbital floor is accessed from the orbital rim. This involves an incision inside the lower eyelid to the orbital rim, allowing the contents in the orbit to expand into the maxillary sinus below.
  • After the decompression surgery is allowed to heal, strabismus surgery may be necessary in cases of double vision caused by thyroid disease.

How long does the operation take?

The length of the surgery depends on the number of walls that require decompression. Typically, the procedure takes between two and three hours and is done while the patient is under general anesthesia.

Is the surgery painful?

After the surgery, some patients may experience mild pain for a day or two which can be managed with over-the-counter medications such as paracetamol or co-codamol.

How safe is orbital decompression surgery?

Surgery to correct bulging eyes is generally considered to be safe and can help restore a more normal eye appearance. However, it is associated with a risk of double vision, which usually resolves on its own. In very rare cases, it can lead to vision loss. Mr. Ahmad Aziz can discuss the risks and benefits of this procedure in detail with you at his London clinic.

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