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Thyroid Related Eye Problems (Graves’ Disease)

What is Graves’ Disease?

Autoimmune thyroid related disease can cause a wide range of symptoms and problems for the eyes, including bulging, redness, tearing, irritation, double vision, pain, pressure, and rarely, loss of vision. The eye problems can start before, after, or during the thyroid problem, and typically progress slowly over about 18-30 months. For a minority of people, the problems are minor and completely resolve, but for most people, the discomfort and change in appearance are long-lasting.

What causes Thyroid Eye (Graves’) Disease?

Thyroid eye disease (also known as Graves’ disease) is an autoimmune disease in which a person’s immune system mistakenly begins to ‘attack’ the thyroid gland and the tissues around the eyes.  Cells in both of these areas have  protein on their surface (called an antigen) in common, and the immune system begins making antibodies against this protein.  This initiates inflammation that causes redness & swelling, loss of function, and scarring.  The exact cause isn’t yet known, but we do know that thyroid eye disease is more common in women and is more common in people with other autoimmune diseases including celiac disease, autoimmune gastritis, and myasthenia gravis.  Not everyone has problems with both the thyroid gland and the eyes, but there is research evidence that removal of the thyroid gland may be protective for the eyes.

What are some symptoms of Graves Disease?

Thyroid eye disease (also known as Graves’ disease) has many eye symptoms and these vary a great deal among different people.  The most common are tearing, burning, redness, and dryness of the eyes.  Also very common are increased sensitivity to light, swelling of the eyelids, and an achy pain or pressure behind the eyes.  Sometimes this pain is worse with eye movement or worse in the mornings.  Bulging of one or both eyes is common and often the eyes appear to open too widely.  This is sometimes first noticed in photographs.  Less common are redness and thickening of the skin around the eyes, eyebrows, and cheeks.  Even less common is the symptom of double vision.  This can occur intermittently, or only when looking in certain directions, or all of the time, and is a little scarier than the other symptoms above because it affects visual function more profoundly.  Even less common (and more scary) than double vision is loss of vision, which occurs in less than 1% of people with thyroid eye disease, and can start as a greying or loss of color vision in one eye.  Noticing any group of the symptoms above would be a good reason to see an eye doctor, but loss of vision is potentially an emergency since treatment is needed urgently to save eyesight. 

Since many people with thyroid eye disease also have thyroid disease itself, we should review some of those symptoms too.  Most people with new onset of Graves’ disease will have hyperthyroidism, which means that their thyroid gland is producing too much thyroid hormone.  Common symptoms of hyperthyroidism are anxiety, tremor, rapid heart beat, unexplained weight loss, intolerance to heat, change in menstrual pattern, and swelling in the neck.

Dr. Fante has lectured extensively on Thyroid Eye Disease, and his recent lecture “Thyroid Eye Disease: the State of the Art, and What We Still Don’t Know” was published nationally by the Audio-Digest, an audio magazine for continuing physician education.

Listen to Dr. Fante discuss Thyroid Disease

How can you test for a Thyroid Eye Disease?

A specialist, who listens carefully to a person’s symptoms, examines the person, and evaluates blood tests and imaging studies, usually makes the diagnosis of thyroid eye disease clinically.  The blood tests usually include thyroid hormone function tests, and also measurement of the antibody against the thyroid receptor that is common to the eye area and the thyroid.  This is called the TSH receptor antibody and the test is usually called TSI (for thyroid stimulating immunoglobulin).  It is not a perfect test, but higher values generally follow more severe disease, and a value above 400 is at higher risk.  Common imaging studies include CT scans and MRI scans of the eye area (called the orbit) that will typically show thickening of the eye muscles and/or fat around the eye.  Imaging is also helpful to show that there isn’t something else (such as a tumor) causing the person’s symptoms.

How can I make my thyroid eye disease easier to control?

Overall, only about half of the people with Graves’ hyperthyroid disease will develop the related eye disease.  But research has shown that several things are protective and will make it less likely that a person with the thyroid disease will get the eye disease too.  Not smoking is the first of these – people with Graves’ should not smoke. Other recent research indicates that statins (drugs usually prescribed for their cholesterol lowering effect) may be protective.  Finally, there is evidence that surgical removal of the thyroid gland may be protective.  There are several options for treatment of the excessive thyroid hormone in people with Graves’ hyperthyroidism and these include surgical removal of the thyroid gland, ablation (destruction) of the thyroid gland with radioactive iodine, and use of pills that suppress thyroid hormone production.  Each of these has advantages and disadvantages and should be discussed with a qualified medical professional such as an endocrinologist.

What can I expect during treatment?

Treatment for the eye disease is typically initiated during the active phase while inflammation is evident, and sometimes involves oral and intravenous medications, radiation, eye drops, ointments, and prism glasses.  Dr. Fante is one of a handful of Colorado specialists who commonly treat this disease.  Treatment is coordinated with primary care physicians or endocrinologists as needed.  Tobacco use is very harmful in this disease and patients are admonished to stop smoking.

For many patients, reconstructive surgery is very helpful in restoring normal function and appearance to the eyes.  Three possible phases of rehabilitative surgery are used as needed: orbital decompression to reduce eye bulging, eye muscle surgery to reduce double vision, and eyelid surgery to restore normal size and shape.  Most patients do not need all of these phases, and many need no surgery at all.


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Will there be scars?

All incisions leave scars.  We’re all different when it comes to scarring, and it’s partly determined by our heredity. Some of us form small, faded scars rather easily. Others form larger, more pigmented scars. This is not always easily predictable. However, any prominent scars can be treated by minor follow-up surgery. Dr. Fante makes the incisions as small as possible, and uses natural lines whenever possible so that scars are generally discreet and hidden for the best overall outcome for you.

What can I expect during recovery?

Most surgical procedures that are performed in an operating room will cause swelling and bruising and will have sutures that require care for the first week or two.  During this period, you’ll be able to see, move about, and accomplish a lot, but you will probably have at least one “black” eye.  You will be asked to avoid strenuous activities for the first week or two, and if necessary, you will be given more specific instructions on travel, bathing, and post-op care.  Your healing will be dependent on which procedure you are having done, your compliance to pre and post-operative instructions, and your overall health. We will do our very best to make sure that you have all the information you and your caregivers will need to provide the best care possible. We are always here to help and available if any questions or concerns arise.

Schedule a consultation

If you are interested in treatment for Graves Disease, contact our Denver, CO office today! Call (303) 839-1616 to schedule a consultation with Dr. Robert Fante.