What is it?

It is known by the name of Graves’ disease or thyroid ophthalmopathy. Patients with thyroid disease, mainly hyperthyroidism, may present a series of ocular alterations that mainly affect the eyelids, the extraocular muscles (those responsible for ocular motility) and the orbit. The ophthalmological picture usually appears a few months after the thyroid disease.

Causes

In hyperthyroidism, the thyroid gland produces excess hormones, apparently due to the presence of antibodies that attack the thyroid gland. These antibodies can also affect, in addition to the extraocular muscles, the soft tissues of the orbit and periorbital region, causing their inflammation.

Diagnosis

The diagnosis is clinical. Although, in most patients, thyroid involvement tends to precede eye problems by months or years, some patients present with an ocular condition. Initial symptoms consist of a sensation of pressure around the eyeball, eye irritation and / or tearing. It is generally a bilateral process (affects both eyes), but asymmetric (affects one eye more than the other).

In a patient with hyperthyroidism, the following ophthalmological changes occur:

·         Retraction of the eyelids: Inflammation of the extraocular muscles, causes the eyeball to project forward (exophthalmos), which causes eyelid retraction (both upper and lower eyelids).

·         Exophthalmos (“bulging eyes”). Inflammation of the extraocular muscles pushes the eyeball outward.

·         Eye dryness: Eyelid retraction and eye prolapse cause dry eye. The eyes are exposed to different environmental aggressions (wind, dust, pollen).

·         Diplopia (double vision): Eye inflammation may not be symmetrical, causing diplopia (eyes are not perfectly aligned).

·         Optic neuropathy (optic nerve disease): Inflammation can put pressure on the optic nerve, leading, in the most severe cases, to cause blindness.

·         Tear trough deformity (bags under the eyes): The swelling of the eyelid can cause the tissue around the eye to protrude. This is perceived as “bags” around the eyes and can make a person appear older than they are.

Treatment

At the beginning, the treatment can be symptomatic, relieving the problems of dry eye (tears, lubricating ointments, occlusion of the tear duct), the use of protective glasses (sunglasses) is indicated. During the active phase of the disease, intravenous corticosteroids may need to be prescribed. In other more severe cases, radiation therapy to the orbit may be necessary.

In the most severe cases, surgery may be indicated.

If there is a high risk of loss of vision due to compression of the optic nerve or in cases of aesthetically unacceptable exophthalmos, an orbital decompression can be performed, which consists on the removal of part of the bones of the orbit that surround the eyeball to allow excess pressure that exists inside the orbital cavity is transmitted to the sinuses that surround the orbit.

In the inactive phase of the disease, rehabilitative surgery may be recommended to improve the aesthetic appearance of the patient. For example, exophthalmos could be corrected by orbital decompression, while lid retraction or eye bags could be corrected by lid / periorbital surgery. Double vision could be corrected by muscle surgery.

Like any surgery, it has associated risks, such as the risk of bleeding or a slight, transitory and mild inflammation of the area.

Prognosis

It is essential to identify the picture in the early stages to minimize its impact. In the cases that require it, orbital decompression and rehabilitative surgery provide good results.