Approximately 70% of thyroid disease sufferers will at some point develop problems related to their eyes. Referred to as Grave’s disease, the eye changes associated with thyroid disease are seen in all types of thyroid disorders. Most commonly, they develop in patients who are or were hyperthyroid (overactive thyroid). Eye problems can occur in patients who have an underactive thyroid or even normal thyroid. Although it is important to control the thyroid hormone levels for medical reasons, the eye disease is not necessarily related to the control of your thyroid levels. Smoking is a significant risk factor for developing thyroid eye disease. Most people will develop thyroid eye problems within 1 year of their thyroid diagnosis. While most eye problems related to thyroid disease are mild, some can be quite disfiguring and traumatic. There is a great deal that can be done to evaluate and treat patients with thyroid related eye problems.
Double Vision
The immune system’s attack on the eye muscles and their subsequent accumulation of fluid make eye muscle movement problems in thyroid eye disease common. Patients will often complain of double vision and can be noted to have asymmetric or abnormal movement of their eyes. It is important for the patient to understand that this problem requires some stabilization and that correction is possible. Conservative management includes the incorporation of prisms into your eyeglasses. Eye muscle surgery may be performed to realign the eyes as well.
Eye Protrusion or Eye Bulging
The same process that causes abnormalities to the eye muscles and increases the fluid in the eye muscles and orbital fat will cause a forward displacement of the eyeball, simply because of the increased volume in the bony eye socket. As the eye protrudes forward, it can cause several problems. Cosmetic deformity along with the upper eyelid retraction can give the characteristic thyroid stare. Excessive protrusion may make eyelid closure difficult and therefore, eyeball and corneal protection may be compromised. Correction of the upper eyelid retraction and removal of prolapsing orbital fat pockets of the eyelids may help to camouflage the abnormal appearance. When severe, orbital decompression can be utilized to expand the volume of the eye socket and allow the eyeball to achieve a more normal position. We will discuss these considerations with you.
Vision Loss
The most dreaded complication associated with thyroid eye disease is vision loss. This is related to the increase in volume in the eye socket. The eye socket can be thought of as a “cone” where the apex has all of the eye muscles and nerve fibers crowded in a very tight space. Any increase in volume of the eye muscles and orbital fat can compress the optic nerve in this small space. This may not be noticed at first by the patient, but may be uncovered by color vision testing and formal peripheral visual field testing. It can also be evidenced by abnormal response to pupil examination. When severe, it can even be noticed by the patient as a loss of central vision. This serious problem is often referred to as compressive optic neuropathy. Compressive optic neuropathy is usually treated immediately with oral steroids and planning is made for orbital decompression surgery. Occasionally, radiation treatments can aid in treating this problem. Although this is an uncommon problem, it is imperative that all patients with thyroid eye disease be evaluated on an ongoing basis.
Smoking and Thyroid Eye Disease
While we do not have all the answers to the thyroid eye disease puzzle, we do have good evidence that patients with thyroid eye disease will exacerbate their problems if they smoke. Furthermore, patients who stop smoking, often benefit with an improvement in their thyroid eye disease. Smoking cessation will also improve the healing process should you require surgery.
Cosmetic Considerations
People with thyroid eye disease often have a characteristic stare related to eyelid retraction and the protrusion of the eye that occurs. Additionally, they may show significant orbital fat prolapse and fluid accumulation, which can account for significant bags around the eyelids. Every patient should understand that while thyroid eye disease can be very frustrating, it can also be treated. With patience and perseverance, together we can accomplish a lot to improve your comfort and appearance.
About Teprotumumab (Tepezza)
Tepezza is a new biologic compound that inhibits insulin like growth factor 1 that is an important molecule that is involved in instigating thyroid eye disease. This is a medication that is given intravenously over a course of 8 weeks. This medication was FDA approved in early 2020 and has shown promise as a medical treatment to reverse some of the inflammatory findings of thyroid eye disease.