Grave’s Disease (Grave’s Orbitopathy or G.O.), Thyroid Eye Disease (T.E.D.)

The eye and the thyroid are closely related in the case of immunological disease that affects them both simultaneously as in the case of Grave’s Disease. This condition causes hyperfunction of the thyroid gland and ocular and orbital complications.

Females tend to be affected more commonly than males, even though the ocular condition tends to be more severe when males are affected. The age more frequently involved is around the late forties early fifties; however, it is quite common to see young ladies in their thirties affected, and very rarely even children can show signs of the disease.

When a thyroid dysfunction runs in the female branch of the family members, it shows a higher risk to be affected sometime during their lifetime. Cigarette smoking seems to be the main factor inducing the disease and worsening the course of the disease in a direct way (dose correlated).

The relationship between thyroid disease and eye disease (orbitopathy) is somehow variable and not strictly correlated in time and course. It would be intuitive to think that the thyroid will be the first to show signs and symptoms, but in 20% of cases, the eye component will show signs and symptoms before any thyroid dysfunction (normal blood tests).

In rare cases, only the eye will show signs of Grave’s, and the thyroid will not be affected. Therefore the role of the oculoplastic surgeon is of paramount importance in diagnosing many patients with Grave’s Disease.

Clinical Course
Grave’s Disease tends to affect patients in many possible ways. Still, we can recognize each time two phases of the illness: the first phase, called ‘active phase’ or inflammatory, is characterized by signs and symptoms of inflammation, which occurs at the very beginning of the disease.

Pain, redness, swelling red-eye, puffiness of the eyelids, pain with movements of the eyes, tearing all can occur and manifest jointly with specific signs of the thyroid eye disease such as exophthalmos (prominence of the eye globes), upper lid retraction, double vision, and visual impairment.

Patients most often will look at themselves in the mirror as completely different from their original aspect as they look with big bulging eyes too widely open (scary look). This phase can last from 2-3 months up to 12-18 months.

The second phase, called the ‘inactive phase’ or fibrotic, is characterized by a resolution of the inflammation, the eyes turn back to white, the swelling disappears, the pain will cease. What will happen to the eyes is somehow difficult to predict if the patient is left untreated in the active phase and spontaneously evolves in the fibrotic phase, but roughly 60% will improve, while the remaining patients will remain stable or get even worse.

This means that there are many patients that may show permanent signs and symptoms of thyroid eye disease. In fact, what remains after the inflammation is gone will stay for the time being unless the patient undergoes surgical rehabilitation.

Acute Phase Treatment
In the first part of the disease, the treatment is determined mainly by the endocrinologist (thyroid specialist preferably), with two goals: the primary goal is to control the thyroid dysfunction trying to keep the hormone levels under control.

This may require medical therapy (tapazole), surgery (removal of the thyroid gland), or radioactive iodine treatment (RAI). The other goal is to reduce and control the eye component during its active phase by administering steroids, usually intravenously or by mouth.

A relatively new form of treatment is periocular steroids injections, where we administer the steroids with a small injection directly in the orbit, so to reduce the undesired systemic effect of the steroids and at the same time maximize the effect of the steroids where is more needed (periocular area).

Treatment of the Fibrotic Phase
Once the disease has spontaneously exhausted and the inflammation is resolved, there are no indications to the medical treatment for the eye disease. At the same time, the patient is encouraged to keep treating the thyroid dysfunction to preserve the hormonal balance within the normal range.

When the exophthalmos (eye bulging) persist, and the scary look remains, only a surgical treatment may affect the clinical appearance of the affected patients.

Orbital Decompression
The surgical decompression of the orbits is the primary procedure aimed to correct the aesthetic disfigurement resulting from the exophthalmos.

The procedure has evolved quite considerably in the last 10 years in the hands of orbital surgeons (mostly ophthalmologists with subspecialty training in oculoplastic surgery).

Nowadays, orbital decompression aims to enlarge the bony orbit to allow the increased volume behind the eye globe to expand in the adjacent sinuses. The eye globe is allowed to sink back in a more natural, healthy, comfortable, and aesthetically pleasant position.

The procedure may require the decompression of one or more of the orbital bones dependently on the severity of the exophthalmos, but it is performed with any visible scar, with minimal side effects. Patients are operated on in general anesthesia and discharged within 24 hours, and can resume work in a week’s time.

At the time of the decompression, the eyelid can be treated if required, and the final effect is aimed at the ‘pre-disease’ condition.

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