Austin McCormick

                                                  Consultant Ophthalmic and Oculoplastic Surgeon MBChB, FRCOphth


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Tel: 01517098442                             Fax: 01517097509                                Email:                               Address:  86 Rodney Street  L1 9AR UK

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Thyroid eye disease

What is thyroid eye disease?

  1. Also known as Graves’ Orbitopathy, this is an inflammatory disease of the orbital tissues.

  2. It is associated with an overactive thyroid gland.

  3. It is an autoimmune disease. This means that the body’s immune system is inappropriately producing antibodies against thyroid gland tissue and orbital muscle and fat. In other words the immune system is attacking the body’s own tissue. It is not known why this happens.

  4. There are many different autoimmune diseases that affect almost all the different tissues in the body.

  5. Rheumatoid arthritis is another such condition, where the immune system attacks the cartilage in joints causing joint inflammation: swelling and pain.

  6. Autoimmune diseases follow similar courses. They have an active phase when inflammation is present followed by an inactive phase when there is no inflammation.

  7. Active inflammation usually means the following symptoms and signs: pain, swelling, redness, loss or altered function of the affected tissue e.g. double vision when eye muscles are inflamed.

  8. Inactive inflammation may mean a complete recovery to normal. However in some people the active inflammation causes scarring or destruction of tissues. When the inflammation becomes inactive there may be permanent loss of function or damage caused by this scarring e.g. persistent double vision due to scar tissue in eye muscles in Grave’s orbitopathy or a joint that won’t bend properly in rheumatoid arthritis.

  9. Usually symptoms of an overactive thyroid gland precede the orbital problems but not always. For some, the first sign of any problem is orbitopathy (eye problems).

  10. Your care is usually coordinated between an endocrinologist, an orbital surgeon and sometimes an endocrine surgeon. You may also be treated with Radio Iodine in a Nuclear Medicine Department.

What are the symptoms and signs of thyroid eye disease?

  1. Your eyes may feel swollen, sore, watery, gritty.

  2. Your vision may become blurred.

  3. The ability to see colour may be different in one eye compared to the other.

  4. A reduction in vision or a difference in colour perception between the two eyes may be a sign of optic nerve compression. This is an emergency and you should see an ophthalmologist urgently.

  5. The eyelids may become swollen and red.

  6. The white of the eye may become red.

  7. You may have pain in and around the eye.

  8. You may experience pain on eye movements

  9. The muscles that move the eye become swollen and may limit how well the eye moves. This in turn may cause double vision (seeing two images). If you have double vision you should not drive. Contact the DVLA for advice.

  10. The eyeball may protrude or bulge forwards.

  11. The eyelids may retract. The upper lid is pulled upwards and the lower pulled downwards. This causes the white of the eye to be revealed above and below the coloured part of the eye. This may produce a staring eye appearance.

How is smoking linked to thyroid eye disease?

  1. Most people who have this condition are smokers.

  2. Whilst it may not be the only reason you have it, there is a strong association.

  3. If you smoke, the condition is likely to be more severe.

  4. If you continue to smoke you are more likely to have a flare up or return of active inflammation.

  5. If you continue to smoke any flare ups you have are likely to be more severe.

  6. The overwhelming evidence is that you should stop smoking if you have this disease.

  7. It is difficult to stop smoking and that most doctors tell patients to stop smoking whenever they attend a clinic. In this situation however there is hard evidence that smoking makes this condition worse and every effort must be made to stop.

  8. Most people are not successful when trying to stop on their own. Most success stories are those who seek help through a smoking cessation programme from their GP or using nicotine replacements. Click here for help on smoking cessation.

What tests may be carried out to determine if I have thyroid eye disease?

  1. Mr. McCormick will examine you in clinic, making measurements of your eyes and vision.

  2. You will also see an orthoptist. This is a health care professional who specialises in eye movent disorders. They will take very careful measurements of your eye movements and note any double vision that you have. The may also be able to help with double vision, either by applying a stick on prism to spectacles or with occlusion of one eye.

  3. You will need to have a blood test. The thyroid hormone levels and antibodies to thyroid gland tissue will be assessed.

  4. If at any point you require treatment with immunosuppressant drugs (steroids, Azathioprine etc) you may need to have more blood tests before and during treatment.

  5. In addition, blood pressure and the skin prick test for diabetes may be used before and during steroid therapy.

  6. A CT or MR scan of the orbits is usually carried out. 

How is thyroid eye disease treated?

  1. Firstly the thyroid gland hormone levels must be brought under control. This is done by an endocrinologist. Usually this occurs before orbitopathy problems but they may occur at the same time or visa versa. Control of thyroid hormones may be with drugs, radioactive iodine drink or thyroid gland surgery.

  2. For orbitopathy there are two stages of treatment depending on ‘activity’.

  3. If inflammation is active, the treatment is aimed at suppressing this inflammation but only if severe enough. Most people have mild disease that doesn’t require immunosuppression.

  4. Types of immunosuppression include: oral steroids, intravenous steroids, Azathioprine and orbital radiotherapy.

  5. Oral steroids start at a high dose and then gradually reduce over a period of months.

  6. Intravenous steroids are given via a drip. They may be given as a day case and repeated 1 week later. This may continue weekly, increasing the dose each time up to a maximum. It is discontinued if no response to treatment is seen.

  7. Azathioprine is started at a low dose and gradually increased according to side effects  and response to treatment.

  8. Localised orbital radiotherapy is delivered in small doses by an oncologist. It acts by suppressing the inflammation in the orbit by inhibiting the cells that cause inflammation. Although usually used for cancer treatment it is an effective anti inflammatory treatment. The time to maximum effect for the treatment is 6 weeks so you may need to be on steroids as well during the intervening period.

  9. The side effects, risks and benefits of each of these treatments will be discussed with you in clinic. Click here for further information about steroid therapy.

  10. Rarely, if vision is threatened by compression of the optic nerve in active inflammation, an orbital decompression may be required. Click here for details of this operation.

  11. If you have double vision this may be treated with a prism in spectacles or patching one eye. This is performed by an orthoptist in clinic. The prism used first of all is called a Fresnel prism and is stuck onto your existing glasses (or a new pair if you don’t currently wear them). Eventually, if the double vision is stable, the prism may be incorporated into the glass lens in spectacles.

  12. The second stage is inactive inflammation. After the inflammation has become inactive you will be reassessed to determine if surgery to rehabilitate you may be of benefit. This is discussed below.

What operations are performed for thyroid eye disease?

  1. As already mentioned, rarely an orbital decompression is required in the active inflammation stage, when sight is threatened and immunosuppressants have failed to control the disease.

  2. Most surgery however is carried out in the inactive inflammatory phase.

  3. The surgery appropriate for you will depend on what problems you are having.

  4. An orbital decompression is carried out to reduce the amount of proptosis or protrusion of the eyeball. Often eyelid retraction improves as well but not always. It may improve symptoms of pressure behind the eye and pain on eye movements. It may improve eyelid closure and therefore improve ocular surface symptoms such as grittyness and dryness. Click here for details of orbital decompression surgery.

  5. Strabismus or squint surgery may be performed if you have double vision. A colleague of Mr McCormick’s, Mr Ian Marsh is the regional expert in this double vision surgery. He also works at Aintree NHS Trust and at 86 Rodney Street, Liverpool. See contact details at the top of the page.

  6. Eyelid retraction surgery aims to correct the retracted eyelid position by raising a lower eyelid or dropping an upper lid. Click here for details of eyelid retraction surgery.

  7. Blepharoplasty surgery is performed to reduce the protrusion of fat from the orbit into the eyelids and to remove any excess skin. Click here for details of blepharoplasty surgery.

  8. The order in which surgery is carried out is as follows: orbital decompression; strabismus (squint) surgery; eyelid surgery.

  9. Usually one side of surgery is carried out at a time. After orbital decompression surgery a period of at least 4-6 months is required before strabismus surgery may be performed. This is to allow the inflammation and swelling caused by orbital surgery to settle. This means that if you go ahead with all the surgery available for Grave’s orbitopathy it may take several years. Most people however do not need all and treatment is tailored to their individual problems.

Click here to see before and after photographs                                                                 Thyroid-eye-disease-photos.html