How Thyroid Eye Disease/Graves' Disease Affects Eye and Eyelid Position

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A 22-year-old woman noticed that one of her eyes is larger than the other, and the right eyelid has drooped as well. She was diagnosed with thyroid issues and wants to know how to correct this.

Dr. Amiya Prasad is a board certified cosmetic surgeon with original training in eye surgery followed by training in oculoplastic surgery which is surgery of the eyelids and the lacrimal system. He specializes in thyroid-related eye disease. The term that is typically used in his field is thyroid-related immune orbitopathy or TRIO. Another term that is more commonly used is Graves' disease. This disease is caused by an autoimmune response where antibodies affect both the thyroid and the soft tissue of the eyes. A common misconception is that the thyroid is affected by creating too much thyroid hormone called hyperthyroid, too low thyroid, or hypothyroid, or normal thyroid, or euthyroid. There’s often a misunderstanding that there’s a direct relationship between the thyroid hormone and the changes in the eyes. However, the thyroid and the eyes are affected by the antibodies. Her endocrinologist will can manage her with either medication or radioactive iodine to reduce the thyroid. There have been studies that say that when the thyroid levels are high, the eye changes are worse. Unfortunately, a person can have very well controlled thyroid levels but their eye changes can go on for years.

Dr. Prasad explains that thyroid-related immune disease is divided into two stages: the inflammatory stage and the fibrotic stage. The inflammatory stage is the stage this woman is in right now where there are continuous changes in the eye shape and the eye may push forward, become very red, retract and a staring appearance will occur. This stage affects the muscles and the fat around the eyes and the eyelids. This stage can last up to 5 years, but in his experience it lasts about two years. There are a lot of different options of how to manage this depending on how the eyes are affected. Management options include observation, the use of steroids as well as the use of radiation and this will be determined by her doctors as things develop.

For surgical options, Dr. Prasad waits for the fibrotic stage. This is the time where the disease finally burns out and appearance becomes more stable. The way to determine stability is by doing exophthalmometry which measures the relative position of the eye. He also does continuous examination and photography to make sure that the eyes are stable. Once it is stable, he has many different medical options such as the treatment of eyelid retraction and eye position. There are also many patients whose eyes don’t need surgery as they resolve to the point where there are no obvious signs. There are also people who have very bulgy eyes, or they are crossed eyed, or they have one retracted, or one eyelid higher than the other. This is a disease that affects a lot of people, particularly women who tend to be younger and can be very emotionally devastating. Fortunately, she is in good company because a lot of people have experienced this and being in practice for over 20 years, Dr. Prasad has been through this process with a lot of people.

It’s important that this woman continues to do what she’s doing with her medical doctors, but she must not be too eager to do surgery too early. The only true indication why Dr. Prasad operated on somebody was when their optic nerve or the nerve that supplies their eyes was getting compressed, or they were developing such exposure at the cornea at the front of the eye. Otherwise, he tries to avoid doing surgery until the fibrotic stage. He explains that she is in the right track in terms of her research but she must not do anything too early or without consensus and the awareness that her disease process has been stabilized.