Graves’ Disease and the Eyes

The thyroid gland is located at the front area of the neck. Its function is to make hormones that control how the body converts food to energy (metabolism). In some people, their immune system interferes with their thyroid, causing it to produce an excess of hormones. It is this excess production of hormones that is known as Graves’ Disease, or hyperthyroidism. Nearly half of people with Graves’ Disease also suffer from Thyroid Eye Disease (TED) as a result. Thyroid Eye Disease affects the muscles and tissues around the eyes.

Symptoms of Thyroid Eye Disease

Not everyone with Graves’ Disease will experience eye problems, and everyone will experience them differently, or even intermittently. Some more common eye problems include:

Eye protrusion (proptosis)

Muscle swelling causes muscles surrounding the eye to push the patient’s eye forward, leading to a bulge that can make it look like the person is staring. This is a very common visible symptom of the disease and can be very traumatic, especially to women, as it changes the physical appearance of the face.

Eyelid retraction

The most common symptom of Thyroid Eye Disease is eyelid retraction. As the muscles in the eyelids swell, both the lower and upper eyelids can pull back, or retract. When this happens more of the white of the eye shows. Eyelid retraction and eye bulging contribute to ‘staring’ look. 

Dry eye

When the eyelids retract and the eye protrudes, exposure to dust and wind increases, often leading to dry eye. Dry eye symptoms include a scratchy feeling, light sensitivity, and blurry vision. If dry eye becomes severe enough, it can even cause damage to the cornea leading to pain and vision problems.

Baggy eyes

Swollen tissue surrounding the eyes can become more pronounced, leading to baggy eyelids that make a person look older or tired. This finding can be worse in the morning and improve as the day progresses.

Changes in vision

The eye muscle swelling associated with Graves’ Disease can lead to double vision, which can be very debilitating in everyday life. It can also put pressure on a person’s optic nerve, which connects the eye with the brain. Pressure from swollen eye muscles on the optic nerve can damage it and lead to blindness. This is a true ophthalmologic emergency and should be addressed immediately with medical or occasionally surgical intervention.

Treatment for Graves’ Disease

During your appointment, your Oculofacial Plastic Surgeon will review your symptoms and conduct an examination of your eyes. Treatment might be required if you continue to experience eye protrusion and eyelid retraction or start showing signs of optic nerve compression.

Some simple options for treatment include:

• Reducing eye muscle swelling by taking steroid medication (oral Prednisone)
• Using an eye ointment or artificial tears to help relieve symptoms caused by dry eye
• Wearing sunglasses to reduce discomfort from light sensitivity
• Treating double vision with prism correction eyeglasses
• If you are a smoker, quitting smoking can help reduce symptom severity

If further treatment is needed, the FDA recently approved a new drug Tepezza (teprotumumab-trbw) for treatment of Thyroid Eye Disease. This drug is administered by infusion (i.e., through an IV). It was proven to improve bulging of the eyes during the active phase of the disease. It can also help alleviate symptoms around the eyes and may even eliminate the need for surgical correction.

Finally, if surgery is necessary to address muscle problems or optic nerve compression, your Oculofacial Plastic Surgeon will discuss these options:

• Address upper eyelid retraction by performing a quick surgical procedure in the operating room. This can improve the appearance of the eyes and reduce dry eye symptoms.
• Reduce the appearance of bulging eyes by removing bone and fat behind the eyeball (from the eye socket) which creates more space for the eye to fall back into the eye socket, which in turn improves appearance of bulging eyes.
• Improve the double vision by moving eye muscles around and removing scar tissue. This is usually performed by a Pediatric Ophthalmologist.
• Prevent vision loss by relieving pressure on your optic nerve.

If you suffer from Graves’ Disease and this condition is affecting your eyes, there are options to relieve symptoms. Be sure to discuss the possibilities with your Oculofacial Plastic Surgeon.