Thyroid Eye Disease (TED) or Graves orbitopathy – Patients suffering from hyperthyroidism and the associated Graves orbitopathy (inflammation of the surrounding tissues of the eye), can display very bulgy eyes, also known as exophthalmos. The eyes are in fact positioned too far to the front because of the increment of soft tissue in the bony orbit, i.e. thicker extra ocular muscles and increased amount of orbital fat. Another possible sign of Graves orbitopathy is a visible part of white of the eye above the iris (the colourful part of our eyes) called scleral show, caused by retraction of the upper eyelid as a result of inflammation of the muscle. that moves the eyelid upwards. Also redness of the eyes, irritation, foreign body sensation and double vision are possible sign of TED. In the inflammatory stage the eyes can also be frankly inflamed and red, and the nasal part of the eye can show a thick pinkish or red structure, that is normally hardly visible. Furthermore, one might experience a rapid increase in eyelid bags, due to the large increment in orbital fat that shows itself protruding forward through the orbital fibrous layer (septum) into the upper en lower eyelids.

For almost all these functional and aesthetically troublesome issues there are medical and surgical procedures that can for a great part correct, or mask, the changes that occurred. Below the most common interventions are listed in the most common chronological order.

  • Orbital decompression. In this procedure the eyes are allowed to be brought backwards by taking out bone and fat from the orbit and as such, making more space in the orbit for the eye to assume its anatomical position.
  • Strabismus surgery. The misalignment between our eyes is called strabismus. In Graves orbitopathy this occurs either primary as a results of an increase in extra ocular muscle thickness, which leads to a change in their movement. And when this occurs asymmetrically or when the patient, for instance, tries to look upwards, it causes diplopia. When strabismus is not present before orbital decompression it can occur afterwards, as during decompression surgery the contents and dynamics of the orbital tissues change. Fortunately, strabismus surgery can almost always solve this bothersome diplopia. This intervention consists of displacing one or more extra ocular muscles of the eye as to better align the eyes and make them work together as they should. 
  • Upper eyelid lowering procedures. There are various ways to lower the eyelid of which we mention here the two most common techniques. If upper eyelid retraction is not severe, a relatively simple removal of a small muscle in the posterior aspect of the eyelid, called the Müllers muscle, can suffice. In cases where upper eyelid retraction is more severe, the levator muscle (see section on Ptosis) that predominantly determines the upper eyelid position, and its upwards movement, is partially or completely liberated from its insertion to let the eyelid descend to a more physiological position.
  • Lower eyelid heightening. Because of the forward protruded eye, the lower eyelid can sometimes also be positioned too low. The lower eyelid can be heightened by liberating the lower eyelid retractor muscle, and inserting a strip of donor tissue or a patients own cartilage, to augment the volume of the lower lid, and as such heightening it. Interventions such as canthoplasty and tarsoraphy can further assist and augment the effect of lower eyelid heightening procedures to ultimately reach a satisfactory functional and aesthetically pleasing rehabilitation.

Please contact us for more information and an intake consultation regarding your queries on thyroid eye disease and dr. van der Veen will be happy to discuss this with you at the clinic.