What is Thyroid Eye Disease (Graves Diseases)?
Orbit is the bony socket which encloses the eyes. Thyroid Eye Disease/ Thyroid Orbitopathy (Grave's Ophthalmopathy) is the commonest Orbital disease. Thyroid Eye Disease can affect the orbit above or behind the eyes and lead to forward, anterior, inferior or superior displacement or proptosis (protruding or bulging) of the eyes. Treatment (medical treatment or surgical treatmrnts like orbital decompression surgery) needs to be administered immediately, as any delay can lead to complete loss of sight.
Dr. Debraj Shome is one of the best/ top oculoplastic ( ophathalmic plastic), orbital and facial plastic surgeons in the world, especially trained in treating eyelid, lacrimal, facial and orbital disorders and diseases. Dr. Debraj Shome is currently based in Mumbai, India.
Thyroid Eye Disease is the most common orbital problem referred to The
Center for Orbital Disease at The Center for Facial Appearances. Dr. Debraj Shome is the regional expert in caring for patients with Thyroid Eye
Disease and have patients that travel from all over the country and the
Thyroid Eye Disease is an autoimmune problem, most commonly noted in
patient with a history of either high or low thyroid hormones. The
disease initially causes the eyes to become red, swollen, and watery.
This initial part of the disease is referred to as the active and
inflammatory phase of the disease. During this early phase of the
disease patients may benefit from treatments that reduce inflammation
such as anti-inflammatory medications or injections and in some cases
referral for orbital radiation. In the later part of the disease the
eyes may bulge out of the socket, the eyelids may be open too wide, or
the patient may have double vision.
asked questions about Graves Disease:
1) What is
Graves’s disease is a disorder that can affect both the thyroid gland
and the eye socket. It is an autoimmune disorder. The immune system can
attack the thyroid gland resulting in high or low thyroid hormone
levels. The immune system can also attack the eye socket resulting
protrusion of the eye from the eye socket, widely opened eyelids, and
or double vision.
2) Who gets
Graves’s disease can affect any age, sex, or race of people. It occurs
more commonly in middle aged woman. The eye problems associated with
Graves Disease are more severe in elderly male patients and in patients
who smoke cigarettes. Graves Disease occurs more commonly in patients
who have other autoimmune disorders like diabetes. Problems with the
thyroid gland sometimes run in families. Sometimes the disease begins
after a period of physical or mental stress.
3) What type of
doctor takes care of patients with Graves Disease?
The problems with the thyroid gland are typically managed by a family
practice doctor, an internal medicine doctor, or by a specialist in
endocrinology. In some patients the thyroid gland may be surgically
removed by a surgeon. The problems with the eyes are managed by an
ophthalmologist or by a specialist in ophthalmic plastic surgery. The
physicians at the Center for Facial Appearances are board certified in
ophthalmology and have a subspecialty in ophthalmic plastic surgery.
Our physicians work as a team with the doctor managing the thyroid
4) Do all
patients with thyroid gland problems develop problems with the eyes?
The majority of patients with either high or low thyroid gland problems
never require eye treatment.
5) Do all
patients with Graves’s eye problems have abnormalities of the thyroid
As many as 25% of patients have no problems with the thyroid gland when
they are diagnosed with Graves’s eye disease. This is called Euthryoid
Grave's disease. Many are surprised to learn this. However, this makes
sense when you realize that Graves’s disease is not caused by abnormal
thyroid hormone levels it is caused by the immune system. The immune
system may only attack the thyroid gland or it may only attack the eye
socket. It will not necessarily attack both at the same time.
1) Can Graves’s
disease cause loss of vision?
Graves’s disease can cause loss of vision by either damaging the cornea
or damaging the optic nerve. Graves’s disease can also cause you to
develop double vision. The vast majority of patients who are
appropriately diagnosed and treated do not loose vision from this
disorder. Those who develop double vision can typically be markedly
improved with treatment.
Graves’s eye disease affect both eyes?
At the onset of the disease it is very common for one eye to be
effected more than the other. In some cases it may be so asymmetrical
so as to only affect one eye. Graves’s disease is the most common cause
of bilateral protrusion of the eyes from the eye socket and it is also
the most common cause of unilateral protrusion of an eye from the
socket. However, when only one eye is affected it is important to get
an MRI or CT scan performed to exclude the possibility of a tumor in
the eye socket.
3) How does
Graves’s disease cause double vision?
When the immune system attacks the eye muscles in Graves Disease the
muscles swell. Swollen eye muscles can cause the two eyes to point in
different directions resulting in the sensation of double vision. The
double vision is often worse when looking up or to the sides and better
when looking down. Double vision should be evaluated promptly by an eye
4) How does Graves’s disease damage the cornea?
Graves’s disease pushes the eyeball forward in the eye socket and also
causes the eyelids to open widely. This can create a situation called
lagophthalmos where the eyelids do not close completely. If the eyelids
do not close normally it causes the cornea to dry out and can
contribute to getting an infection or ulceration in the cornea. The
initial symptoms of this are a dry sensation on the eye or a feeling of
having something in the eye. If the cornea develops an infection or
ulceration the eye will typically become quite red and painful. A
corneal ulcer is an ophthalmic emergency and should be evaluated by an
eye care professional on the day it occurs.
How does Graves’s disease damage the optic nerve?
nerve is the nerve that carries vision from the eyeball to the brain.
The nerve exits the back of the eye socket at the orbital apex. The
nerve is surrounded by the eye muscles at the orbital apex. If the eye
muscles are swollen enough they pinch off the optic nerve and can cause
loss of vision. When this occurs it is called thyroid related optic
neuropathy. Thyroid related optic neuropathy is an ophthalmic emergency
and it should be evaluated on the day it occurs.
6) How do I
know if Graves Disease is affecting my vision?
If you have concerns with your vision for any reason you should be
evaluated by an eye care professional. At The Esthetic Clinic, we also
recommend that patients with Graves Disease self assess their vision on
a daily basis with your spectacles on. This is done by performing two
simple tests on a daily basis. First of all cover the left eye and read
a paragraph from the newspaper. Repeat the test with the right eye
covered. If you note a change in your ability to read the fine text in
the newspaper with one or both eyes then call your eye care
professional. Also put a red magnet on your refrigerator. Alternately
occlude the two eyes and note the color of red. If the magnet begins to
look less red in one or both eyes then call your eye care professional.
7) How is the
diagnosis of Graves Eye Disease made?
In some cases the diagnosis is straight forward. For instance, in a
patient with a history of abnormal thyroid hormone levels who begin to
develop bulging eyes and double vision the diagnosis is fairly easy. In
some cases the eye problems will cause the doctor to suspect Graves
Disease and a blood test to evaluate the thyroid hormone levels will be
ordered. Some patients suspected of having Graves Eye Disease will be
found to have normal thyroid hormone levels. In these cases a special
test called the anti-TSH receptor antibody test may help in making the
diagnosis. It is sometimes useful to obtain a CT scan or MRI scan of
the eye socket. If the scan demonstrates enlargement of the eye muscles
this is supportive of the diagnosis. If you have had blood test done to
evaluate your condition please bring the results to you consultation
with Dr. Debraj Shome. If you have had MRI or CT scans done of the orbit,
please bring the images (the actual film or CD disk) with you to your
consultation. Bringing the report prepared by the radiologist is not
8) What is Type I and Type II Grave’s Eye Disease?
Type I Graves disease is when patients develop bulging forward of the
eyes from excess fat in the eye socket but without swelling of the eye
muscles. Type II Graves disease is when the eyes bulge forward because
of swollen eye muscles. Patients with Type II Graves disease are more
likely to have troubles with double vision because of the abnormally
large eye muscles.
1) What are the
stages of Graves Disease?
The first stage of Graves disease is called the either the ascending
stage or the active inflammatory stage of the disease. During the first
stage of the disease the symptoms of the disease such as protrusion of
the eyes and double vision may get worse. In this stage of the disease
use of anti-inflammatory medications may reduce symptoms. The second
stage of the disease is the descending stage. In this stage of the
disease symptoms tend to partially improve but typically do not improve
to normal. The last stage of the disease is the stable stage. About 90%
of patients do not have significant changes in their Graves Disease eye
symptoms for the rest of their life once they enter the stable stage of
the disease. 10% of patients can have what is called reactivation of
disease where they enter a 2nd active and inflammatory stage of the
disease after achieving the stable stage. Smoking cigarettes can be one
thing that triggers reactivation of the disease.
2) Why is
staging of Graves Disease important?
The proper treatment for Graves Disease depends on the stage of
disease. Patients in the active and inflammatory stage of the disease
may require treatment with anti-inflammatory medications. Most surgeons
try to avoid performing surgery during the active and inflammatory
stage of the disease. Patients need to be monitored for loss of vision
during the active inflammatory stage of the disease because this is
when optic neuropathy or trouble closing the eyelids can put a patient
at risk for loss of vision. Some patients with Graves disease may need
surgery to correct problems caused by Graves disease. Surgery is
typically performed during the stable stage of the disease.
3) How do I
know if I am in the active inflammatory stage of the disease?
Sometimes this can be determined by history. So if your eyes bulged
forward many years ago and have not changed in the last year you are
probably in the stable stage of the disease. If your eyes were normal 2
months ago and you have noted them becoming more open and bulging
forward then you are probably in the active stage of the disease. Red,
swollen, and tearing eyes are symptoms associated wit the active
inflammatory stage of the disease. Sometimes looking at old photographs
can be useful in determining when your eyes changed or for how long
they have been stable. Measurements of the eyelids, eye movements, and
protrusion of the eye are made when you see your eye doctor. If these
measurements are getting worse you are in the active inflammatory stage
of the disease. If these measurements are stable for 3-6 months you are
in the stable stage of the disease.
Graves Disease: Ascending or active inflammatory stage
1) What can be done to reduce the symptoms of dry eye or feeling like I
have sand in my eyes?
Use of an artificial tear containing 0.5% carboxymethylcellulose such
as Refresh Plus every two hours during the day combined with the use of
a lubricating ointment such as Refresh PM just before going to bed at
night can reduce symptoms substantially. If your eyes still feel dry
with this treatment discuss it with your doctor.
2) What role
does prednisone or steroid pills play during the active and
inflammatory stage of the disease?
Taking oral steroids reduces symptoms in most patients in the active
inflammatory stage of the disease. However, it requires fairly high
doses of steroid given for a prolonged period of time. There are many
side effects of being on high doses of steroids for a prolonged period
of time including: weight gain, high blood pressure, development of
diabetes, trouble sleeping, and psychological disturbances. The
physicians at The Center for Facial Appearances do not routinely
prescribe prolonged treatment with high dose oral steroids during the
active and inflammatory stage of the disease.
radiating my thyroid gland improve my eye symptoms during the active
inflammatory stage of the disease?
Radiation of the thyroid gland will reduce your thyroid hormone levels
but it has also been associated with worsening eye disease. We feel it
is important that the doctor managing your thyroid hormone levels be in
communication with the doctor managing your eye disease so a decision
can be made on the best treatment. In some patients the thyroid hormone
levels can be reduced with anti-thyroid medications such as methimazole
(Tapazole) or propythiuracil (PTU). These drugs do not cause worsening
of the eye symptoms. In some patients the thyroid hormone levels cannot
be controlled with these medications and radiation of the thyroid gland
during the active and inflammatory stage of the disease may be
unavoidable. In these cases it may be helpful to use steroids before
and after the thyroid gland radiation. Another option for controlling
the thyroid hormone levels is surgical removal of the thyroid gland.
This should be discussed with your team of physicians.
radiating my eye sockets help my eye symptoms during the active
inflammatory stage of the disease?
It is clear that radiation is not beneficial once your eyes are in the
stable stage of the disease. Despite a number of studies there is
disagreement among experts if radiation is useful during the active
inflammatory stage of the disease.
5) What role do
orbital injections of steroid play during the active inflammatory stage
of the disease?
Patients who are in the active inflammatory stage of the disease that
are not threatened with loss of vision are often treated with
injections of orbital steroids by the physicians at the Center for
Facial Appearances. Orbital steroid injections are particularly useful
in patients with pain in the eye socket caused by Graves’s disease. Our
doctors have also found orbital steroid injections useful when tapering
patients off of systemic steroids. Orbital steroid injections do not
cause systemic side effects such as weight gain, hypertension and
diabetes. However, there are potential complications to be considered
when giving injections of medicine adjacent to the globe.
6) What role do
intravenous steroid injections or pulsed dose intravenous steroid
injections play in the management of the active inflammatory stage of
Patients that have severe or vision threatening disease are often
treated with once weekly infusions of steroids. We have found these
injections to be as effective in treating severe inflammation as oral
steroids but to have fewer systemic side effects than oral steroids.
Patients go to an IV infusion center once weekly for four or more
weeks. It is important that blood test are ordered to monitor for
complications of the weekly steroid injections.
Graves Disease: Stable stage
1) What role do medications or eye drops play during the stabe stage of
There is no pill or intravenous infusion that is known to be helpful to
patients during the stable stage of the disease. Many patients will
have dry irritated eyes and will benefit from treatment with artificial
tears and eye lubricating ointment as described above. Surgery is the
primary mode of treatment for patients with Graves’s disease during the
stable stage of the disease.
2) Do all
patients with Graves Eye disease require surgery?
The majority of patient with Graves Eye disease will not develop
problems severe enough to require surgical correction.
problems might be improved with surgery?
Patients with eyes that protrude from the eye socket may be helped with
orbital decompression surgery. Patients with double vision may be
helped with surgery on the eye muscles which is termed strabismus
surgery. Patients with widely open eyes or excess fat deposited in the
eyelids can have this corrected with surgery. A consultation with Dr. Debraj Shome can further inform you if you may benefit from surgery.
4) If a patient
has protruding eyes, widely open eyes, and double vision can all of
these problems be addressed with a single surgery?
Graves’s disease often requires more than one stage of surgery. In the
first stage of surgery orbital decompression surgery is performed to
place the eyes back into the eye socket and to reduce the retraction of
the eyelids. Some patients will require an additional stage of surgery
to correct double vision and some another stage of surgery to remove
fat deposited in the eyelids.
5) What are the
indications for performing orbital decompression surgery?
In the past orbital decompression surgery was reserved for patients at
risk of permanently loosing vision. Dr. Debraj Shome still has to perform
emergency orbital decompression surgery for patients who are losing
vision during the active inflammatory stage of the disease. However,
the majority of orbital decompressions are performed on an elective
basis for patients with pain behind the eyes, dry irritated eyes, and
for patients who have been disfigured by bulging of the eyes. This
should be discussed with a qualified surgeon.
6) What are the
indications for performing surgery for widely open eyes or eyelid
If your eyes are dry and irritated and you have white showing between
the colored part of your eye and the upper or lower eyelid then you are
likely a candidate for surgery. This should be discussed with a
7) What are the
indications for strabismus surgery?
If you have double vision when looking straight ahead or down or if you
have to take a chin up posture to see single you are likely a candidate
for surgery. This should be discussed with a qualified surgeon.
8) Are their
risk involved in surgery for Graves’s disease?
Yes. All medical and surgical procedures have risk associated with
them. We believe the risk of surgery can be reduced by having an
experienced surgeon perform your procedure. When patients come to us,
Dr. Debraj Shome evaluates them and then discusses the risk benefits and
alternatives of treatment so that patient may make an informed decision.
9) Will my
insurance company pay for reconstructive surgery for Graves’s disease?
Each insurance company has its own policy. In general your insurance
company will pay for procedures that improve your vision, make your
eyes less dry and irritated, and reduce pain behind the eyes.
Procedures performed where the only goal is to improve appearance are
typically not covered.
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