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The Thyroid Eye Institute offers a wide variety of options to improve conditions resulting from thyroid eye disease including bulging of the eyes, puffiness, redness, pain, dryness, irritation, and closed eyelids. 

About Thyroid Eye Disease

Thyroid eye disease (TED), also known as Graves’ ophthalmopathy, is an autoimmune disorder that causes inflammation and swelling of the eyes and can stimulate the production of muscle tissue and fat at the back of the eye. This infection tends to cause frustrating and uncomfortable issues, such as red eyes and eyelids, swollen skin, and bulging eyes. 

What Are The Symptoms?

The tissue around the eye is usually the main target for thyroid eye disease, resulting in inflammation and swelling which also causes:

  • BULGING OF THE EYES
  • DRYNESS AND IRRITATION, AS THE EYELIDS MAY NOT SHUT ENTIRELY.
  • REDNESS AND PAIN IN THE EYE
  • PUFFINESS AROUND THE EYES

As TED symptoms tend to be progressive, if swelling continues without treatment, additional symptoms can include:

  • INCREASED PRESSURE WITHIN THE EYE SOCKET
  • HEADACHES OR MIGRAINES THAT WORSEN WITH EYE MOVEMENT
  • DECREASED VISION, AS SWOLLEN TISSUES MAY HAVE PUSHED THE OPTIC NERVE
  • DOUBLE VISION DUE TO RESTRICTION OF THE EYES’ NORMAL MOVEMENTS
  • A “STARING” APPEARANCE: THE EYE BULGES

TREATMENT OPTIONS FOR THYROID DISEASE

Thyroid eye disease progresses through two primary phases: Active and Inactive. The phase of active inflammation can last from several months to two years, during which dryness and redness in the eye will likely be prominent. In the inactive phase, the condition may have settled down—but patients may be left with effects such as protruding eyes, and may require additional treatment. 

Treatments for thyroid eye disease include:

  • SELF-CARE: TREATMENTS YOU CAN CARRY OUT YOURSELF INCLUDE QUITTING SMOKING, WEARING SPECIAL SUNGLASSES, USING EYE DROPS, WEARING SPECIALLY DESIGNED SPECTACLES FOR DOUBLE VISION, AND AVOIDING EXPOSURE TO IRRITANTS LIKE DUST.
  • CORRECTING THYROID HORMONE LEVELS: MEDICINE IS ADMINISTERED TO ADJUST THE LEVELS OF THYROID HORMONES IN THE BLOOD.
  • STEROIDS: THESE ARE POWERFUL MEDICINES THAT HELP CONTROL INFLAMMATION.
  • RADIOTHERAPY: THIS IS CONSIDERED DURING THE ACTIVE PHASE IF STEROIDS HAVE BEEN INEFFECTIVE.
  • PRESCRIPTION TREATMENTS SUCH AS TEPEZZA
  • SURGERY: FOR SEVERE AND PERSISTENT SYMPTOMS, SURGERY IS USUALLY CONSIDERED. SURGERIES INCLUDE EYELID SURGERY, EYE MUSCLE SURGERY, OR ORBITAL DECOMPRESSION SURGERY.

Eyelid Retraction Repair

Thyroid eye disease, also called Graves disease, can cause inflammation that results in swelling and damage to the eyelid muscles. This can cause proptosis, or eyelid retraction where the eyelids are pulled back from the front of the eye. Dr. Gay performs eyelid retraction repair with orbital decompression surgery, a procedure that removes the bones and sometimes fat in the eye orbit in order for the eyes to be adjusted back to a more normal position.

Upper eyelid surgery

To improve upper eyelid retraction, surgical loosening of the upper eyelid retractor muscles (levator muscle and Mueller’s muscle) and release of scar tissue in the muscles is performed to allow the upper eyelids to come down to a more normal level. This surgery is typically done with local injections and minimal IV sedation in order to permit patient cooperation during the surgery. Patients are placed in a sitting upright position at the end of surgery to ensure adequate surgical correction. Adjustments made during surgery diminish the risk of asymmetry following surgery. Despite meticulous attention to eyelid height during surgery, the eyelids may heal differently resulting in eyelid asymmetry. 

Frequently, the asymmetry is not bothersome and further surgery can be avoided. In up to 10-15% of patients, additional “touch-up” procedures may be needed to correct significant asymmetries. Significant upper eyelid retraction repair is typically considered medically necessary, and is usually covered by most insurance carriers. Mild cases of eyelid retraction may be considered cosmetic. At the time of upper eyelid retraction repair, patients may elect to have excessive fatty tissue and redundant skin folds excised. Upper eyelid blepharoplasty is frequently considered cosmetic, and is not typically covered by most insurance carriers.

Lower Eyelid Surgery

The same puffiness and tissue response that occurs in the upper eyelids may also develop in the lower eyelids. Lower eyelid retraction may result in exposure of the white portion of the eye. This may contribute to eye exposure, dryness, and irritation. Surgical procedures can improve the protection of the eye and the appearance of the lower eyelid. With lower eyelid surgery, the scarred muscle can be loosened and spacer material inserted to boost the eyelid upward. Spacer grafts used might include ear cartilage, porcine, or dermal implants. To be able to reposition the outer edge of the lower eyelid upward, the outside tendon must be tightened.

Despite meticulous measurements of spacer materials, the eyelids may heal differently resulting in eyelid asymmetry. Frequently, the asymmetry is not bothersome and further surgery can be avoided. Additional “touch-up” procedures are infrequently indicated to correct significant asymmetries. Significant lower eyelid retraction repair is typically considered medically necessary and is usually covered by most insurance carriers. At the time of lower eyelid retraction repair, patients may elect to have excessive fatty tissue and redundant skin folds excised. Lower eyelid blepharoplasty is frequently considered cosmetic and not covered by most insurance carriers.

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Orbital Decompression Surgery

Orbital decompression surgery can often improve proptosis by enlarging the eye socket (orbit) to accommodate the swollen fat and muscle tissues behind the eye. This allows the eye to settle back into a more comfortable position. The consistency and amount of fat varies from case to case, and will impact the degree of decompression achieved by surgery. Individuals with thicker, stiffer fat may not experience as much decompression effect as those with large amounts of softer, more fluid-like fat tissue.

Around the orbit (the bone socket in which the eyeball sits), there are a number of sinus cavities that can be used to surgically expand the orbit. The sinus below the eye is called the maxillary sinus, and the sinus toward the nose is called the ethmoidal sinus. A maxillary-ethmoidal bone decompression is a well-recognized approach for accommodating the extra tissues behind the eye. Most people only require a two wall, maxillary-ethmoidal decompression; occasionally, the outside (lateral) wall of the orbit may also be removed.

What happens during orbital decompression surgery?

The surgical method utilized by Dr. Gay to remove the bone of the orbital floor (underneath the eye) involves an incision on the inside of the eyelid and a very small skin incision near the outer corner of the eye. This skin incision heals nicely within the normal laugh lines around the eye. Using eyeglasses with magnification, Dr. Gay will meticulously remove the bone of the orbital floor to allow communication with the maxillary sinus air cavity.
 There is a nerve that runs through this bone to provide sensation to the cheek, lip, and upper teeth. Great care is taken to meticulously nibble the bone away from this nerve so that the nerve is preserved.

Despite extreme caution and the use of micro-surgical techniques, some numbness almost always occurs. However, in more than 90% of cases, this numbness is only temporary. To remove the medial orbital wall bone, Dr. Gay may use a very small conjunctival incision near the inside corner of the eye. Alternatively, he may work closely with an otolaryngologist (ENT surgeon) who performs an endoscopic ethmoidectomy. This is a procedure in the nose that permits access to the same area. After the bones of the orbit/sinuses are removed, the tissues which have built up behind the eye (fatty tissue and/or swollen extraocular muscles) are able to expand into the maxillary and ethmoid sinus cavities.

TEPEZZA

Tepezza is an FDA-approved prescription treatment for thyroid eye disease. It is delivered intravenously on-site at The Thyroid Eye Institute in a multi-session treatment schedule over the course of a few weeks. Tepezza has proven very effective in:

  • REDUCING ORBITAL PAIN, REDNESS AND SWELLING IN THE EYE
  • IMPROVING FUNCTIONAL VISION OF PATIENTS AND THE APPEARANCE OF THE EYES
  • DECREASING PROPTOSIS (BULGING OF THE EYES)
  • CORRECTING OR IMPROVING DIPLOPIA (DOUBLE VISION)
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Dr. David Gay is a highly experienced master ophthalmologist specializing in eye surgeries of all kinds, including those required to treat thyroid eye disease and its effects. Providing the highest level of patient care and results, Dr. Gay remains abreast of all research and innovation in his field, and is proud to be able to offer Tepezza and other options to his Austin patients. If you’re looking for a renowned Austin ophthalmologist to help you treat and correct TED, please schedule a consultation with us at The Thyroid Institute at 512-559-3544, or contact us online.

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