Graves Ophthalmology, Eye Surgery and Blepharoplasty

Graves' disease can sometimes manifest as Graves' ophthalmopathy and may necessitate eye surgery and blepharoplasty (surgical modification of the eyelids). If Graves' ophthalmopathy (also called Graves' eye disease or infiltrative thyroid ophthalmopathy) is diagnosed, and if simpler procedures don't help the condition, doctors may recommend eye surgery.

Graves' disease is the most common form of hyperthyroidism (over-production of thyroid hormones). Correct functioning of the thyroid is essential for general well-being. Incorrect functioning has an impact on the nervous, digestive and reproductive systems as well as on other organs, one of these being the eyes.

Graves' disease is considered a disease of the auto-immune system whereby the body sees one of its parts to be foreign and sets out to destroy it. In the most common type of Graves' disease, the thyroid (a gland in the throat) is seen as the enemy. Because it is being attacked by antibodies the thyroid becomes over-active and typically, swollen.

In a small percentage of patients, one of the complications of hyperthyroidism is thyroid optic neuropathy which occurs when pressure is placed on the optic nerve by the swelling caused by the disease. This pressure causes moderate to severe loss of sight. In some cases there is a change in the perception of colour. In more serious cases there may be complete loss of eyesight. It may also lead to drying of the cornea, which may become opaque.

Other symptoms of Graves' ophthalmology are swelling of the muscles around the eye, inflammation and protrusion of the eye, swelling of the eyelids (upper and lower), pain, double vision (sometimes) and loss of vision (rarely).

Exophthalmos (forward protrusion of the eye) can be quite disfiguring as the eyes appear to be bulging outwards. Depending on the severity of the condition, several options are available. Certain medications such as steroids or prescription strength eye-drops may reduce the inflammation behind the eyes and/or relieve the symptoms.

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Treatment is dependent on the severity of the condition. Mild symptoms may be managed by using artificial tears and lubricating gels. Steroids, taken orally, may be prescribed with mild redness, pain and pressure being treated with medications such as Advil. Prednisone pills may be prescribed.

Orbital decompression
In severe cases, surgery may be needed to relieve the pressure on the eye. Such surgery is termed orbital decompression. Bones will be removed where the pressure is greatest ie the innermost part of the eye socket between the socket (orbit) and the sinuses. This allows more room for the enlarged muscles, relieves the pressure and allows the eye back into its socket. This will protect the vision and improve comfort and appearance. There is minimal bruising and no external scarring as the incisions are placed within the eyelids.

Eye muscle surgery
Eye muscle surgery is another option. The inflammation can affect the eye muscles making them too short. If the eye muscles cannot perform or synchronise effectively, double vision may result. This can be extremely disturbing for sufferers. Special prescription prism glasses may be prescribed but they don't suit everyone.

Eye muscle surgery involves realignment of the eyes by cutting the muscle and re-attaching it further back. Muscle surgery may be carried out under local anaesthesia with intravenous sedation.

Should the eyelids open too widely, abnormal blinking occurs and natural lubrication of the eyes is affected. In exceptional cases of retracted eyelids, blepharoplasty (eyelid surgery) may be called for to reduce the irritation.

Eyelid surgery is not usually carried out until the disease has stabilised. Once stabilisation occurs, eyelid surgery will improve the appearance of the eyes. It will also improve the health of the eyes, allowing proper lubrication and protection of the eye. Such an operation may involve the use of the CO2 laser to minimise bruising and speed healing. Attendance as an outpatient may be all that is required.

Should all three surgical procedures be recommended, orbital decompression is carried out first followed by eye muscle surgery and finally eyelid surgery.

The symptoms of Graves' ophthalmopathy can be distressing and may last for some time. The disease is much more common in smokers. The inflammation can last from six months to two years and doesn't always coincide with the onset of the disease in the thyroid. Problems with the eyes may precede hyperthyroidism but may also occur at the same time or even years later. The more usual tests for Graves' ophthalmopathy may not indicate any problems and further investigation may be needed to reveal abnormalities.

Moreover, treatment of hyperthyroidism does not always affect the progression of the eye problems. Generally women between the ages of 20 and 45 years of age are affected by Graves' ophthalmopathy.

Generally local measures only are called for. Ten percent of cases will require further treatment with anti thyroid drugs, orbital (eye socket) radiotherapy or surgery.