What is thyroid ophthalmopathy?
The term thyroid ophthalmopathy or thyroid orbitopathy refers to ocular and periocular changes associated with thyroid diseases. Although thyroid ophthalmopathy (TO) can occur in any type of thyroid disease, the vast majority of cases occur in patients with Graves’ disease (hyperthyroidism) . OT rarely occurs in patients with primary hypothyroidism or even in patients without evidence of thyroid disease. In the latter case, hyperthyroidism frequently develops months or years after the diagnosis of OT.
Why can it occur?
Hyperthyroidism can cause a wide variety of eye problems , including red eyes, irritation, photophobia, periocular edema, double vision, vision loss, eyelid retraction, and eye protrusion. It’s important to know that there are different degrees of OT, and experiencing one of these symptoms doesn’t mean the others will develop.
In Barcelona, we offer a unique service for these patients. We offer a multidisciplinary service comprised of an endocrinologist specializing in thyroid surgery, a thyroid surgeon, and an oculoplastic surgeon in a single facility. This integration of subspecialties is unique in Spain and is designed to provide the best care for patients with thyroid ophthalmopathy, eliminating the need to visit specialists at different centers and ensuring complete communication between them.
Once the eye disease appears, it typically remains active for a period that can range from 6 months to 2 years. During this time, an active inflammatory process exists, so the appearance of the eyes and the severity of the disease may vary. During this period of inflammatory activity, it is advisable not to perform surgery unless there is a risk to vision, but there are many other measures that can help improve the patient’s symptoms. Once the eye disease is stabilized, it is very rare for the process to reactivate . In some patients, the eyes will return to normal, while in others the changes will be permanent. At this point, some patients will be candidates for surgery to improve ocular protrusion, double vision, or eyelid retraction.
FAQS Oftalmopatía tiroidea
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Various theories have attempted to explain why thyroid orbitopathy occurs. The most widely accepted theory suggests that certain molecules are present in both the thyroid gland and the orbit, so the antibodies produced by the autoimmune process would react against the gland and the orbital tissues. At the orbital level, antibodies react selectively against orbital fatty tissue and the extraocular muscles responsible for eye movement.
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It is well known that thyroid disease and eye disease can follow different courses. That is, eye disease may appear before thyroid disease, afterward, or progress significantly even after thyroid function has stabilized. However, there is evidence that monitoring thyroid function influences eye disease . For example, we know that during the treatment process for hyperthyroidism, phases of hypothyroidism should be avoided, and that treatment with radioactive iodine can temporarily worsen eye disease. Communication between your endocrinologist and your orbital specialist is essential for optimal management of your orbital disease.
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An orbital and eyelid specialist is an ophthalmologist who specializes in diseases affecting the ocular adnexa. As an ophthalmologist, he or she is better than anyone familiar with the periocular structures and their involvement in this disease.
Often, patients with OT, frustrated by their unfortunate condition, consult several specialists in search of immediate solutions. This is a disease that can have a long course and requires patience . It is highly advisable to consult an orbital specialist who will guide you through the entire OT process. They will help you understand your condition and treat it at every stage. Furthermore, they will be in constant contact with your endocrinologist to monitor the status of your thyroid function and make decisions together. While the condition is active, simple measures such as ocular lubrication or sleeping with your head slightly elevated to reduce eyelid edema can be very helpful. The specialist will also determine when your condition has stabilized and whether you are a candidate for surgery. A third very important role of the orbital specialist is to detect the possible onset of more serious complications such as vision loss or corneal involvement, which may require urgent treatment.
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Dry eyes, red and irritated eyes
The sensation of dryness, irritation, and photophobia are by far the most common symptoms of the disease. Ocular protrusion, along with eyelid retraction (eyes that are too wide open), causes the ocular surface to be much more exposed to the environment. As a result, tears evaporate much more quickly and fail to protect the ocular surface. Frequent use of preservative-free artificial tears can greatly alleviate these symptoms. These eye drops have no harmful effects, even if used every 30 minutes, as they do not contain any medication, only lubricating agents. Occasionally, nighttime use of lubricating gels is also advisable, especially if the patient has incomplete eyelid closure.
Double vision
Thyroid orbitopathy causes inflammation and scarring of the muscles responsible for eye movement, impairing their function . When both eyes do not move exactly the same, double vision, or diplopia, occurs. One eye sees a single image while the other sees the same image slightly shifted. In some patients, this phenomenon is only present in certain gaze positions, while in others it is present constantly, which is very disabling. Diplopia can fluctuate throughout the course of the disease, and in some patients, it may disappear once the disease stabilizes. When the disease is stable and double vision persists, surgery may be considered.
Eyelid retraction
It is largely responsible for the fixed or frightened stare that patients with OT display. It occurs because the inflammatory and scarring changes also affect the muscles responsible for opening the eyelids. This is a very common phenomenon in this disease . Whenever possible, surgery should be performed until the disease has stabilized. It is very helpful if you provide photographs from previous years so that the specialist can get an idea of when the changes began and what your eyelids looked like before the disease. The goal of surgery is to return the eyelids to a normal position, which will radically improve the patient’s appearance and better protect the ocular surface.
Thyroid exophthalmos
The orbit is the bony cavity that houses the eye and its associated structures. Inflammation of the orbital tissues causes an increase in their volume. Since the orbit is a bony cavity and therefore non-extensible, the increase in its contents results in a forward protrusion of the eye . In some patients, the orbital tissues are more rigid and do not allow the eyeball to move forward, so the increase in orbital volume results in orbital congestion.
Protruding eyeballs, or exophthalmos, can be treated surgically once the condition has stabilized. This treatment is called orbital decompression and involves increasing the volume of the orbital cavity to better accommodate the orbital tissues enlarged by inflammation, thereby allowing the eyes to recede into a more normal position.
Loss of vision
It can occur for various reasons. The first is corneal damage , which results from the exposure of the ocular surface caused by ocular protrusion and eyelid retraction. In many cases, it can be treated simply with an intense pause of ocular lubrication. In more severe cases, surgical measures will be necessary to ensure corneal protection. The other cause of vision loss is optic nerve compression . The optic nerve is responsible for carrying visual information from the eye to the cerebral cortex. When orbital congestion compresses the optic nerve, vision loss occurs, which can be very marked or slow and subtle, and difficult for the patient to detect. Fortunately, this occurs in less than 5% of patients with OT. Treatment varies depending on the case but may include intravenous corticosteroids, radiation therapy, or surgery.
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Stop tobacco
There is currently no evidence that smoking induces ophthalmopathy. However, it is well known that smoking increases your chances of developing more severe forms of the disease . Smoking increases your risk of vision loss with this condition. Furthermore, if you are a smoker, you are more likely to experience flare-ups of the disease, and your surgery may have a lower success rate. We often find patients who notice a significant improvement in their eye symptoms within a week of quitting smoking.
A patient with thyroid ophthalmopathy in the inflammatory phase. Her appearance improved significantly one month after quitting smoking.
Endocrinological control
Proper control of hyperthyroidism is essential to increase your chances of better control and less severe ophthalmopathy. This may include oral medication, radioiodine, and, in refractory cases, thyroidectomy . A close relationship between your endocrinologist and your oculoplastic surgery specialist is essential.
Eye lubrication
Exophthalmos and eyelid retraction contribute to greater drying of the ocular surface , which is why we always recommend the use of artificial tears and lubricating gels.
Corticosteroid pulses
These are high doses of intravenous corticosteroids. Treatments are given weekly for 6 weeks, in decreasing doses. They are primarily used when there is optic neuropathy due to compression or in cases of severe inflammation even when there is no neuropathy.
New biological therapies
The use of new therapies is gaining acceptance in the treatment of thyroid ophthalmopathy. In cases of severe inflammation with little response to corticosteroids, or when corticosteroids are not indicated, tocilizumab has demonstrated efficacy . It is a humanized monoclonal antibody that binds to the cellular receptor for interleukin-6 . This interleukin plays an important role in the immune response and is involved in the pathophysiology of several diseases. It is administered intravenously in several sessions.
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There are different procedures that can help us restore the patient’s vision.
Orbital decompression
When exophthalmos is significant, orbital decompression surgery is essential. This surgery essentially consists of improving the “fit” of the eye and its tissues within the orbital cavity . This can be achieved in two ways: by enlarging the orbital cavity (bone decompression) and by reducing its fat content (fat decompression). A combination of both procedures is generally performed.
Bone decompression involves gaining space in the orbit by means of the ethmoid and maxillary sinuses (medial and inferior decompression) or by reducing the volume of the lateral bony wall (lateral decompression). Medial and inferior decompression can be performed through a scarless transconjunctival approach, while lateral decompression can be performed through a small incision hidden in the upper eyelid crease .
This surgery is performed under general anesthesia but does not require hospitalization . Complications are rare when performed properly. These include, for example, the development of diplopia (double vision), which may require subsequent correction with strabismus surgery.
Correction of eyelid retraction
Upper eyelid retraction is performed by weakening the muscles responsible for lifting the eyelid (Muller’s muscle and levator palpebrae). This is done through the conjunctival approach, with local anesthesia and without a scar . For mild retractions, only the Muller’s muscle is usually worked on (mullerectomy), while for larger retractions, the levator palpebrae muscle is weakened in addition.
Strabismus surgery
Patients with ophthalmopathy who present with strabismus require surgery to correct their double vision. Strabismus in this condition is restrictive, due to stiffness of the ocular muscles. The most common deviation is toward the nose (endotropia) or downward (hypotropia), or both. This can be corrected or improved by means of “recession” of the affected muscles . This is performed with local anesthesia without hospitalization. In complex cases, more than one intervention may be necessary.
Blepharoplasty
Many patients with thyroid ophthalmopathy present a prematurely aged appearance of their eyelids. This is primarily due to increased volume of orbital and periorbital fatty tissue, which leads to the appearance of bags. Once exophthalmos, double vision, and eyelid retraction (if present) have been treated, blepharoplasty may be considered.
