The purpose of the thyroid gland, located in the neck, is to produce the thyroid hormone that helps regulate our metabolism. Occasionally it produces too much thyroid hormone or too little. Imbalance in either direction can cause eye and vision problems. The precise cause of thyroid eye disease, which may be very variable in its manifestations, remains a mystery.
A staring appearance and dry eyes are often the first symptoms. Early signs include swelling of the eyelids and tissues around the eye. The eyes can become red and the membrane overlying the white of the eye may swell giving a “jelly-like” appearance above the lower eyelids. Swelling of the normal fat surrounding the eye and the eye muscles can push the eye forward creating a protrusion of the eye.
Once an overactive thyroid gland is suspected, the thyroid function must be evaluated and appropriately treated. The eye disease may continue to progress after the thyroid function has been treated. Any residual eye problems should be followed and, if necessary, treated by an ophthalmologist with expertise in this field.
Treatment should be considered as being in two phases. The first phase involves treating the active eye disease. The active period, which usually lasts two or more years, requires careful monitoring until stable. The second phase involves correcting unacceptable permanent changes that persist following the stabilisation of the active phase.
With rare exceptions surgery for thyroid eye disease is performed in the following sequence (although not every stage is required):
- Orbital decompression
- Eye muscle (strabismus) surgery
- Eyelid repositioning surgery
An orbital decompression is a surgical procedure undertaken to create more space in the orbit. This operation is performed to create more room in the eye socket and is usually performed as part of the management of thyroid eye disease. There are a number of indications that will point to the need for this surgery:
- To relieve compression of the optic nerve by swollen muscles at the apex of the orbit where there is a confined space. This is referred to as dysthyroid optic neuropathy. An orbital decompression may be considered as the main management of this problem or it may be used for patients in whom alternative treatments e.g. steroids, radiotherapy have failed or have caused intolerable side effects.
- To improve the cosmetic appearance of protrusive eyes.
A patient with ‘burnt out’ thyroid eye disease
The appearance following a bilateral orbital decompression and a lower lid transconjunctival blepharoplasty with fat repositioning
- To relieve corneal exposure. A situation where the cornea is exposed due to severe proptosis (protrusion of the eye) with poor closure of the eye resulting in drying of the cornea and even ulceration in advanced cases.
- Constant aching orbital pain due to congestion of the orbital tissues which can be relieved by a decompression procedure.
- The distressing situation where the eyes are so protrusive that they may prolapse out of the orbit especially on attempting to look up. The eyelids may close behind the eye.
- In some patients whose eyes are quite protrusive, the eyes may become more protrusive following eye muscle surgery to improve double vision. In such patients a decompression operation may be considered desirable prior to such eye muscle surgery.
- In some patients, a satisfactory result cannot be obtained by eyelid lengthening procedures alone as extreme protrusion of the eyes is the main cause of the lid retraction. Such patients require an orbital decompression.
Orbital decompression surgery is also being requested more and more frequently to improve the cosmetic appearance of patients as the surgical results and safety of the surgery have improved considerably over recent years. Most orbital surgeons would regard such surgery as rehabilitative (as opposed to “cosmetic”) with an attempt being made to restore a patient’s appearance to that which existed prior to the onset of this disease process. However, such goals are rarely achieved completely and expectations need to be realistic. This surgery is usually performed under general anaesthesia with an overnight stay in hospital. It can be performed on one side initially and then on the other 2-3 weeks later, or it may be undertaken on both sides under the same anaesthetic.
Surgery to deal with double vision is only undertaken when the deviation of the eyes has remained stable for a period of 6 months. Whenever possible, temporary stick on prisms (Fresnel prisms) are fitted to glasses to overcome double vision until surgery is deemed appropriate. This surgery is performed by other colleagues in the region who specialize in strabismus (squint) surgery.
Eyelid repositioning surgery
Upper and lower eyelid retraction may be treated by lengthening the tendons of the eyelid retractor muscles. This is usually performed under local anaesthesia for the upper eyelids. This allows greater accuracy to be achieved with regard to the final height and contour of the upper eyelids. Nevertheless it may be very difficult to achieve symmetry and to avoid a flaring of the outer aspect of the upper eyelids.
A patient with a marked degree of left upper lid retraction
The appearance of the patient 4 months following a posterior approach Mullerectomy and levator recession
Lower eyelid retraction may be treated by means of grafts e.g. hard palate grafts taken from the hard palate (roof of the mouth) usually under general anaesthesia. Often lower eyelid retraction surgery is not required in patients who have undergone an orbital decompression as the eyelid retraction often resolves following such surgery.
Severe eyelid swelling in thyroid eye disease may leave the eyelids with a very “baggy” appearance and with excess skin. Blepharoplasty involves the removal of excess skin and/or fat from the lids. This may improve the appearance of the lids but cannot restore normality. Upper eyelid surgery has to be very conservative to avoid weakening of the reflex blink and any dry eye symptoms.
You will visit the clinic to have a preoperative consultation. This usually lasts 45 minutes. You will be asked to complete a healthcare questionnaire, providing information about your current and past health, about any previous eye, eyelid or facial surgery or treatments including refractive surgery or laser eye surgery, and any previous non-surgical aesthetic treatments e.g. Botox injections, dermal fillers injections, the use of IPL or laser treatments. We need to know if you have a past history of any eye problems e.g. dry eyes, or if you use contact lenses. We need to know about any allergies you may have, medications you are taking (including over the counter products e.g. Aspirin, Indomethacin, Nurofen, Diclofenac or vitamin supplements), previous major surgery or illnesses, any past dermatology history and whether or not you smoke. You will have your blood pressure checked by the nurses at the clinic.
It is very helpful if you have old photographs which you can bring along to the consultation. If you are happy to email digital photographs of your current appearance in advance of the consultation with details of your concerns, this is also enormously helpful and saves time. Your photographs will be kept confidential and will form part of your clinical record.
The nurses are also happy to answer any further questions and to show you the facilities at Face & Eye, including the operating theatre if it is not in use.
If you are unsure of the names of any medications, bring them with you.
You will be told whether or not to stop any medications at this preoperative clinic visit. For example, if you are taking aspirin-containing medicines or anticoagulants, they may need to be temporarily withdrawn or reduced in dose for two weeks before the procedure as long as these are not medically essential. You might need to check this with your GP. Any anti-inflammatory medicines e.g. Ibuprofen, Nurofen should be discontinued at least 2 weeks before surgery. These medicines predispose you to excessive bleeding. You will be given a leaflet advising you on what medications, foods, and vitamin supplements to avoid prior to surgery. Your blood pressure should also be under good control if you take medications for hypertension. This is very important.
If you can, try to stop smoking at least six to eight weeks prior to surgery. Smoking can severely worsen the effects of thyroid eye disease. Smoking also has an adverse effect on healing and damages your eyelid skin and supporting tissues and your eyes (it can result in premature cataract formation and age related macular degeneration with a loss of central vision).
Your vision in each eye will be measured. Your eyes will be examined carefully using a slit lamp (a special ophthalmic microscope). Your tear film status is determined and the back of the eyes (called the retina) is examined as well as the eyelids themselves. The rest of your face is then examined. Photographs of your face and eyelids will be taken before surgery so that the results of surgery can be compared with your original appearance. The photographs are confidential and can only be used for any purpose other than your own records with your specific written permission.
Some insurance companies request copies of preoperative photographs.
The risks and potential complications of surgery should be considered but these need to be kept in perspective. Complications in the hands of a trained and experienced oculoplastic surgeon are very rare and all precautions are taken to minimize any risks.
What are the possible complications of orbital decompression surgery?
Serious complications from orbital decompression surgery e.g. loss of vision, CSF leak (leak of brain fluid), meningitis, are extremely rare. The major potential complication, which must be considered, is postoperative double vision. The incidence of this complication varies considerably from surgeon to surgeon. It is much more of a problem in patients who have some double vision prior to surgery with a risk of up to 30% that this may be worse postoperatively. In patients with no pre-existing double vision, the risk is considerably reduced (<5%). It is rare for any patients who suffer this complication to be left with a significant problem following corrective eye muscle surgery. This risk must, however, be considered very carefully in a patient who wishes to improve cosmesis as this has implications for driving and work. It may be necessary to wait for some months before muscle surgery can be undertaken to improve double vision. In some patients temporary prisms can be fitted to glasses to improve double vision.
Other potential complications which should be considered:
- Loss of sensation in the cheek, side of the nose and front teeth, and in the temple (this usually recovers after a few weeks or months)
- Retraction of the lower and/or upper eyelid
- Reoperation. Further surgery to address any asymmetries may be required. This should be borne in mind. There are a number of factors beyond a surgeon’s control, which can have an impact on postoperative progress e.g. postoperative swelling affecting one side more than the other, which in turn can necessitate re-intervention.
After orbital decompression surgery, the eyes are initially covered with pressure dressings overnight to reduce postoperative swelling. The dressings are then removed and replaced with cool packs. Activity is restricted for 2 weeks to prevent bleeding.
You will be asked to clean the eyelids very gently using clean cotton wool and Normasol (sterile saline) or cooled boiled water and repeat the application of antibiotic ointment (usually Chloramphenicol or Soframycin) to the wounds 3 times a day for 2 weeks. The sutures used are dissolvable but are usually removed in clinic after 2 weeks.
You must avoid blowing the nose or holding the nose when sneezing for a period of one month following the surgery.
You will be discharged on oral steroids for a week, an oral antibiotic a week, analgesics, and artificial tears as well as an antibiotic ointment.
A realistic period of recovery must be expected. Postoperative bruising usually takes at least 2-3 weeks to subside completely. Swelling takes much longer. Most of the swelling disappears after 3-4 weeks but this can vary considerably from patient to patient as does the extent of the swelling. The final result is not seen for at least 3-4 months. This should be taken into consideration when scheduling the operation. You should arrange this surgery after holiday periods or important professional or social events and not before so that you are available for postoperative review and just in case any surgical adjustments are required.
You will need to use frequent artificial tears for the first 2-3 weeks following surgery. It is preferable to use preservative free drops if you have any allergies. These will be prescribed for you e.g. Hyabak drops, Systane eye drops preservative free, Viscotears preservative free, Liquifilm tears preservative free, or Celluvisc drops and Lacrilube ointment at bedtime.
You are advised to sleep with the head raised approximately 30 degrees. It is preferable to raise the head of the bed if possible.
Contact lenses should not be worn for a few weeks following this type of surgery.