Treatment Options for Thyroid Eye Disease

Disease Progression

There are two phases of thyroid eye disease – active and stable. The active phase, marked by inflammation, usually lasts from six months to two years. The focus during this stage is on medical treatment to relieve the eye symptoms.

During the second phase, or the stable phase, inflammation and other symptoms have subsided. The patient may need surgery to correct the more visible effects of the disease.

Thyroid Eye Disease Treatment - Active Inflammatory Phase

Burning Eyes

It is important to restore lubrication during the active phase. The surface of the eye dries out because the eyelids are tight and do not blink properly. Inflammation may cause the tear glands to produce fewer tears. Many patients say they feel as if a forest fire has raced through their eyes. Liquid teardrops (or artificial tears) offer significant relief. Tips on using liquid teardrops:

  • Most patients need to use them regularly—at least four times per day and as often as every hour or two in severe disease.
  • Use non-preserved tears. The preservatives used in some brands can lead to allergies or irritation with long-term use. Brands include Celluvisc, gel preparations such as Moisture Eyes gel, or lubricating ointments such as Refresh P.M. or Lacri-Lube.
  • Thicker preparations are available for those who need additional lubrication.
  • Thicker lubricants can blur vision. Consider using them at bedtime and then use your other teardrops first thing in the morning (to wash out the ointment) and throughout the day.

Other tips:

  • Wear wrap-around sunglasses if your eyes are sensitive to light, wind, or other irritants.
  • Try to avoid direct heat or air conditioning, especially while driving.
  • Use additional artificial tears during activities that cause the eye to blink less and become dry, such as computer use, driving, or reading for extended periods.

Dry Eyes

When your eyes dry out, a reflex occurs, producing massive amounts of tears that flood the eye’s drainage system. The same reflex is observed when you begin to cry after smelling an onion. Unfortunately, your tears provide only short-term relief. As a rule of thumb: if your eyes produce excessive tears, they are probably dry. In dry eye, the outer covering of the eye is sometimes damaged and may be covered with small blisters. Treatments include:

  • Medication to provide moisture, allowing the blisters to heal.
  • A procedure to block the tear drainage system, allowing your own tears to coat the eye instead of draining away. This office procedure is very simple, painless, safe and reversible.

Steroids

Anti-inflammatory medications—chiefly steroids — are available for advanced causes of the disease. To avoid side effects associated with long-term use, steroids are given at higher doses for a month or so and then tapered off. 

With careful monitoring, a second course of steroids can be prescribed for prolonged periods of inflammation. Also, steroids can be injected into the orbit during an office visit. These injections minimize side effects and cause minimal discomfort.

Management of Poor Eyelid Closure

If your eyes remain open during sleep, you may experience severe drying that can damage the cornea. In some cases, the cornea may become ulcerated, resulting in loss of vision. One of the best ways to protect your eyes during the night is to make a Saran wrap dressing that serves as a moisture chamber. During your visit, Dr. Douglas can show you how to make this dressing.

Reducing the appearance of swelling

Unfortunately, a great deal of swelling accompanies thyroid eye disease. You may notice bags under the eyes, increased bulging of the eyes, and swelling of the tissue coating the eyes. Anything that increases the fluid in the body can add to the swelling. Some solutions:

  • Reduce salt in your diet to decrease fluid retention.
  • Sleep with your head raised, allowing fluid to settle out of your face. You can prop up your bed by placing bricks under the head of the bed frame.

Thyroid Eye Disease Treatment – Stable Phase, after inflammation has subsided

Surgical Options

Dr. Douglas is a leader in adopting minimally invasive techniques that can correct the bulging appearance of your eyes, minimize double vision, bring the eyelids into the correct position, and address the sometimes jarring physical changes that come with the disease. Surgeries are “staged” or performed in a specific order. While some patients may achieve desired results with the first surgery, more than one stage of surgery is usually necessary to achieve optimal rehabilitation.

Patients should allow two to four months between surgeries and can normally return to activities one to two weeks after each surgery.

First stage: minimally invasive orbital decompression surgery

Orbital decompression surgery is designed to remove bone and/or fat from behind the eye, allowing the eye to move back into its socket. The surgery makes more room behind the eye for the enlarged muscles that have developed with the disease.

For less severe cases, a technique may be used that removes soft tissue or fibroblast-fat. For moderate to severe disease, patients may need bony decompression, which involves sculpting areas of bone that form the walls and floor of the eye’s orbit.

Surgery can help achieve these benefits:

  • Reduce exposure of the surface of the eye
  • Improve the eyelid’s ability to close over the eye
  • Improve the bulging appearance
  • Relieve pressure-pain
  • Release pressure on the optic nerve, restoring its function and improving vision

Second stage: eye muscle surgery

In thyroid eye disease, scarring can cause permanent damage to the eye muscles. Scar tissue, which forms around muscle fibers, becomes stiff and neither contract’s nor relaxes as easily as the muscle it replaces. The eyes may then become misaligned, causing double vision.

Eye muscle surgery can minimize double vision, but may not completely eliminate it. The goal of this surgery is to create a tunnel of single vision, allowing patients to achieve good straight-ahead vision needed for driving and reading. The patient is able to resume many activities, but still may experience double vision when looking far to the right or left.

The surgery is performed on an outpatient basis with local anesthesia. In eye muscle surgery, the surgeon repositions the muscles, bringing the eyes into alignment. The incisions are hidden. In approximately 5 to 10 percent of cases, more than one surgery is needed to achieve satisfactory alignment of the eyes.

Third stage: eyelid repositioning surgery

Often in thyroid eye disease, the eyelids open too widely. This accounts for the staring appearance associated with the disease, and it causes the eyes to become dry. The opened eyelids give an unnatural appearance to the eye; and because the disease often affects each eye a little differently, the eyelids can become asymmetrical. Occasionally the opposite problem occurs and the eyelids droop.

Eyelid repositioning surgery is carried out under local anesthesia on an outpatient basis. The surgeon releases eyelid muscles or tendons that have become tight, allowing the eyelid to return to a more natural position. Sometimes, particularly in the lower eyelid, tissue is added to reinforce the newly relaxed tissues.

Fourth stage: surgery and sculpting to correct the effects of thyroid eye disease

After these corrective surgeries have been completed, patients often discover that thyroid eye disease has left its mark. Loss of elasticity and puffiness are now permanent features, and the tissues around the eye appear to have aged dramatically.

Once the inflammation has resolved we can address some of these changes with surgery aimed at aesthetic reconstruction, especially in the soft tissue around the eye. Swollen and puffy tissue can be treated with sculpting surgery such as blepharoplasty (eye lift) or facelift surgery. The loss of the skin’s elasticity can be treated with laser resurfacing and injections such as fat or Restylane.

The course of thyroid eye disease is challenging, and it is not unusual for patients to feel discouraged and emotionally drained by the physical changes that accompany the disease. Patients who decide to pursue this fourth stage—aesthetic rehabilitation—are some of the most grateful patients.