Surface Disease / Exposure Dry Eye symptoms
- Hyperthyroidism almost always causes general eye symptoms like dryness and irritation, regardless of what the cause of the hyperthyroid state is.
- Dry, gritty eyes
- Red, swollen eyes and eyelids
- Watery eyes
- Eye pain
- Sensitivity to light
- Bulging eyes
- Double vision
- Retracted eyelids (your eyelids can’t close properly)
Lower Eyelid Retraction
- Graves’ ophthalmopathy generally causes the eyelids to open more widely. The front surface of the eyeball becomes exposed beyond the eyelids and causes discomfort and excessive tearing; exposure keratopathy.
- Eyelid surgery is the most common surgery performed on Graves ophthalmopathy patients.
- Lid-lengthening surgeries can be done on upper and lower eyelid to correct the patient’s appearance and the ocular surface exposure symptoms.
- Marginal myotomy of levator palpebrae muscle can reduce the palpebral fissure height by 2-3 mm.
- When there is a more severe upper lid retraction or exposure keratitis, marginal myotomy of levator palpebrae associated with lateral tarsal canthoplasty is recommended.
- This procedure can lower the upper eyelid by as much as 8 mm. Other approaches include mullerectomy (resection of the Muller muscle), eyelid spacer grafts and recession of the lower eyelid retractors. Blepharoplasty can also be done to debulk the excess fat in the lower eyelid.
- Surgically repositioning the eyelids can reduce the irritation. If orbital decompression, eye muscle and eyelid surgery are required, the eyelid procedure is generally performed as the final procedure in the series.
Upper Eyelid Retraction
- The upper eyelid retraction might be worsened if the eye is unable to elevate normally (strabismus), and extra nerve impulses are sent simultaneously to the muscle which elevates the lid and to the muscle struggling to elevate the eye itself; once the restriction is treated (e.g. strabismus surgery), the degree of retraction often decreases.
- Double vision usually occurs because the eyes are out of alignment.
- Misalignment often is caused by one or more eye muscles that are too short or “tight” because of scar tissue from Graves’ ophthalmopathy.
- This scar tissue results from changes in the eye because of inflammation.
- Prisms may possibly be temporary (pasted on) or permanently ground into your lenses. However, prisms do not work for all people with double vision. Sometimes eye muscle surgery is a more effective treatment.
Eye Muscle Surgery
- The goal of eye muscle surgery is to achieve single vision when looking straight ahead and when reading. During eye muscle surgery the muscle is cut from its attachment to the eyeball and reattached further back. Usually eye muscle surgery does not require an
Orbital decompression involves removing some bone from the eye socket to open up one or more sinuses and so make space for the swollen tissue and allowing the eye to move back into normal position.
The CT above shows the orbit on the left following orbital decompression. Note how the muscle bows inward, into the area of the sinus – now that this orbital wall has been surgically removed.
- Optic Neuropathy. Even though some patients undergo spontaneous remission of symptoms within a year, many need treatment. The first step is the regulation of thyroid hormones levels by an endocrinologist.
- Topical lubrication of the ocular surface is used to avoid corneal damage caused by exposure. Tarsorrhaphy is an alternative option when the complications of ocular exposure can’t be avoided solely with the drops.
- Corticosteroids are efficient in reducing orbital inflammation, but the benefits cease after discontinuation. Corticosteroids treatment is also limited because of their many side effects. Radiotherapy is an alternative option to reduce acute orbital inflammation. Unfortunately, there is still controversy surrounding its efficacy. A simple way of reducing inflammation is smoking cessation, as pro-inflammatory substances are found in cigarettes.
- Surgery could be done to decompress the orbit, to improve the proptosis and to address the strabismus causing diplopia . Surgery is performed once the patient’s disease has been stable for at least six months. In severe cases, however, the surgery becomes urgent to prevent blindness from optic nerve compression.
- Eyelid surgery is the most common surgery performed on Graves ophthalmopathy patients. Lid-lengthening surgeries can be done on upper and lower eyelid to correct the patient’s appearance and the ocular surface exposure symptoms. Marginal myotomy of levator palpebrae muscle can reduce the palpebral fissure height by 2-3 mm. When there is a more severe upper lid retraction or exposure keratitis, marginal myotomy of levator palpebrae associated with lateral tarsal canthoplasty is recommended. This procedure can lower the upper eyelid by as much as 8 mm. Other approaches include mullerectomy (resection of the Muller muscle), eyelid spacer grafts and recession of the lower eyelid retractors. Blepharoplasty can also be done to debulk the excess fat in the lower eyelid.
- If the optic nerve is compromised, and vision is threatened as a result of Graves’ disease, the term optic neuropathy could be applied.
Orbital Decompression Surgery
- In orbital decompression surgery the bone between the orbit (eye socket) and the sinuses (air spaces next to the orbit) is removed.
- A successful procedure improves vision and provides room for the eye to slip back into the orbit’s protection.
- There are possible complications of the surgery, however.
- You could experience lip numbness for several months after the operation.
- Double vision could persist or it could develop anew after surgery
- Orbital volume and dimensions: = 30 cc, 35(Height) x 45(Width) x 45 mm(medial wall depth), globe 25 x 25 mm
- Bones: (F)rontal, (M)axillary,(Z)ygomatic, (L)acrimal, (E)thmoid, (P)alatine, (S)phenoid
- makes room to put the eyes back in the socket and correct the proptosis (bulging).
- the bone between the orbit and the Sinuses (Sinus is the air spaces next to the orbit) is removed.
- goal is to improve vision and provides room for your eye to slip back into the orbit’s protection.
- lid numbness
- double vision
- CSF leak (of cerebrospinal fluid that surrounds and protects the brain)
TEPEZZA has a novel, breakthrough mechanism in Thyroid Eye Disease (TED) designed to block IGF-1R, a key mediator.
Thyroid Eye Disease Pathogenesis:
- Autoantibodies activate the IGF-1R/TSHR signaling complex, which stimulates orbital fibroblasts.
- Once activated, orbital fibroblasts cause potentially severe inflammation and expansion of tissue, muscle, and fat cells behind the eye.
TEPEZZA Mechanism of Action
TEPEZZA targets and blocks IGF-1R and inhibits fibroblast activation via the IGF-1R/TSHR signaling complex at the source of the disease. TEPEZZA targets IGF-1R and decreases proptosis by
- Reducing inflammation
- Preventing muscle and fat tissue remodeling
- Preventing tissue expansion behind the eye
Orbital radiotherapy (ORT) is another approach used to treat TED. This treatment aims beams of energy (radiation) at a precise point on the body. In the case of TED, the area targeted is behind the eye. ORT may provide some symptom relief for some people with TED.