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Thyroid-Related Eye Problems
(Grave’s Disease)

Grave’s disease (hyperthyroidism) is a medical condition in which an over-active thyroid gland secretes an excess amount of thyroid hormone. As a result, you may have an enlarged thyroid gland, palpitations, fast pulse, profuse sweating, high blood pressure, irritability, and a number of symptoms related to the eyes.

If you have been diagnosed as having a thyroid condition, a medical history may suggest that your eye problems are related to it. On the other hand, sometimes the presence of eye symptoms is the first sign of thyroid trouble.

What are the Symptoms?

 In the early stages, the most common eye involvement is lid retraction, a pulling upward of one or both of the upper eyelids. It gives the patient the appearance of staring or being “wide-eyed”. Since the eyes are more exposed to the air, they will feel dry, and in response, the tear glands may secrete more tears than normal. When lid retraction is severe, the eyelids do not close completely, even when you blink. This will make the surface of the eyes even drier, especially during the night when you are sleeping. It can cause exposure keratitis (corneal inflammation), which in turn, may lead to corneal ulceration.

During the acute phase of Graves’ disease, but surprisingly, even more commonly after treatment of the thyroid problem, the eyeballs may begin to protrude or bulge. Called exophthalmos or proptosis, the condition is thought to occur from an inflammatory, auto-immune response in the eye socket that causes swelling, and the swelling pushes the eyeball forward. At times the swelling can become as severe as to endanger the health of the optic nerves.

The same type of inflammation and swelling can also involve the eye muscles. This may cause double vision (diplopia) because the muscles are not able to coordinate the eye movements. Another effect of the swelling may be puffy or baggy eyelids.

Examination

Your pupils will be dilated (enlarged) with eye drops and you will have a complete eye examination, including visual fields and an eye pressure check. An instrument called an exophthalmometer will be used to measure how far forward the eyes have protruded from the eye socket. This instrument does not ever tough the eyes. X-rays of the orbit may be taken to help determine the cause of the eyes’ bulging and to rule out an orbital tumor.

Treatment

The treatment for Grave’s disease includes a combination of drugs, surgery and/or radioactive iodine, to restore normal function of the thyroid and normal thyroid hormone levels in the body. Even after successful treatment; however, it is not unusual to find the eye problems persisting or even continuing to progress for a while. Usually the eye condition will eventually stabilize.

You can help alleviate the drying of the eyeball surface by using artificial tears eye drops. A lubricating ointment can help prevent corneal drying while you sleep. If drying is severe and exposure keratitis is a problem, you may need a minor surgical procedure, known as tarsorrhaphy, to attach the outer corneas of the eyelids together, narrowing the eye opening and keeping the upper eyelid from pulling upward. Later, if the condition improves and lid retraction lessens, the surgery can be undone. After the disease has stabilized, you may wish to have cosmetic surgery to lessen or eliminate the lid retraction.

If bulging of the eyes is severe and corneal exposure or optic nerve damage is not manageable, you may require an operation known as decompression. This involves partial removal of the bone around the eye socket to enlarge the space and relieve the pressure on the eye. X-ray treatment may also help, but the results are often unpredictable.

The double vision occurring in Grave’s disease is difficult to treat. Swelling of the eye muscles may sometimes be helped to some extent with cortisone-related medications. (Steroids) Long term use of these drugs can often create serious side effects. Some relief may be obtained by adding prisms to the eyeglasses. Otherwise, eye muscle surgery may be necessary but unfortunately, even this may not be successful. As a last resort, double vision can always be relieved simply by covering one eye with a removable patch.

The surgical treatment of many of the problems related to thyroid eye disease is often performed in stages. It is rare that a patient regains his or her original appearance, but with persistence and patience, a cosmetically acceptable result is very often achieved.