January 25, 2014

Eye Disease – Thyroid Eye Disease

The ophthalmologist included a lot of material in the email he sent me and the images were not the most usable. I talked to him about that. He said he was aware they might not be, but hoped that they would not be unusable. I told him that I would talk about the images that show in Google search. I asked him why he did not cover thyroid eye disease and he said probably because he does not have any patients with the disease. He thanked me for wanting to cover it and said it does happen in small numbers for people with type 2 diabetes, but more often for people with type 1 diabetes.

Some people refer to this as bulging eyes, but should not. Thyroid eye disease (TED) is a disease marked by swelling of the muscles and fatty tissues surrounding the eyeball within the eye socket. This causes the eyeball to be pushed forward and causes various eye symptoms. Treatment is done to protect the eye while the disease runs its course. This often means artificial tears, medicines, and in some cases, surgery. Thyroid eye disease is usually associated with an abnormality of the thyroid gland, which needs to be treated.

TED is sometimes called other names such as thyroid ophthalmopathy, dysthyroid eye disease, Graves' ophthalmopathy or ophthalmic Graves' disease.” Autoimmune thyroid disease happens when the body's antibodies attack the thyroid gland. In some people, these same antibodies also attack the tissues surrounding the eyeball.

TED is a rare condition and affects about 16 women and 3 men in every 100,000 people each year. Most of the people have an overactive thyroid gland and have an underlying autoimmune condition. It generally happens in middle age and some people carry genes that make it likely that they will have thyroid eye disease.

Symptoms are caused by the tissues of the eye socket swelling and pushing the eyeball forward:
  • The front of your eyes can get red and irritated as the sensitive cornea is less well covered or lubricated by the eyelids.
  • The front of your eyes may feel (and be) dry if the tear-producing gland (the lacrimal gland) has been affected.
  • Your eyes may ache.
  • Your eyes may look more bulgy, giving you a staring appearance.
  • You may get double vision (diplopia) as the muscles become too swollen to work properly.
  • In advanced disease, your vision may become blurred and colors can appear less vivid.

The two eyeballs are not always equally affected. You may have other non-eye symptoms due to the abnormal thyroid gland.”

Diagnosis of TED can be done in several ways:
#1. An eye exam if you already have a diagnosis of a thyroid gland problem.
#2. A blood test named thyroid function tests which determines how well your thyroid
gland is functioning or more specialized blood tests to measure the antibodies in your blood.
#3. Thyroid scans to see how actively the thyroid gland is working and sometimes an MRI, which will show which tissues have been most affected.
#4. They can also assess your general sight, how well your see colors, and how your peripheral vision is. They may also carry our an eye movement test to see how the eye muscles have been affected. These assessments will often be repeated throughout the course of the disease.

If left untreated, the inflammation will gradually heal itself; however, the symptoms caused by the swelling may remain because some of tissues have been stretched to the point they will not return to their original form. Treatment is done to limit the damage done during the inflammation.

Medicines may be used, such as artificial tears, which are ocular lubricants, and this may be sufficient in the early stages. As the disease progresses, steroids such as prednisolone may be used. Omeprazole, a medicine that protects the stomach lining may be used to counteract the side effects of steroids.

In about five out of 100 people with TED, the disease is severe enough to require surgery is required. Several types of surgery can be accomplished:
  1. Decompression – creates a space within the orbit for the inflamed tissues to spread into for relieving pressure on the optic nerve.
  2. Surgery on the orbit to allow the eyeballs to settle back into the sockets.
  3. Surgery to the stretched muscles or to the lids to allow return to normal.

There are other treatments available and you may read about them here.

Here are a few tips that you can do to help yourself:
  • We know that one thing that makes this disease worse is smoking. If you do smoke, see your GP about getting help to stop.
  • Sleeping propped up will help reduce the puffiness (congestion) around the eyes.
  • You may find bright light uncomfortable. Sunglasses will help.
  • If you are a driver, let the DVLA know if you experience double vision. This is a legal requirement. Usually, they will contact your ophthalmologist for a report. If the double vision is well controlled with prisms, you may be declared fit to drive.”

Most people with TED do not develop permanent complications; however, when TED is severe, the person is older, a person smokes, and in people with diabetes, complications cannot be ruled out. Some possible complications include:
  1. Complications from the disease
  • Damage to the clear window of the eye (the cornea).
  • Permanent squint or double vision.
  • Damage to the nerve of the eye, resulting in poor vision or color appreciation.
  • Unsightly appearance.
2. Complications from treatment
  • Side effects from the immunosuppressive medicines.
  • Side-effects from the surgery:
    • New double vision (about 15 in 100 people with TED).
    • Loss of vision (less than 1 in 1,000 people with TED).
    • There are some other very rare complications that your surgeon will talk you through.”

Thyroid Eye Disease is a drawn-out illness. The inflamed period generally lasts months to about two years. For most people it will be a mild disease needing lubricants and regular assessments only. It fades away by itself. For those who have a more severe disease, the outlook depends on how early it is diagnosed and how intensive the treatment is. About 1 in 4 people will end up with reduced eyesight.

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