Procedure: Orbital Decompression and eyelid surgery

Graves Eye Disease (Thyroid eye disease) is an autoimmune disease that effects our eyelids and orbits. The hallmark of the eyelid disease is eyelid retraction which is when the upper and lower eyelids are pulled above and below the colored edge of the eye. Patients will often have what is described as a ‘staring’ look to their eyelids. Patients can also have protrusion or bulging of the eyes.

In 5% of patients there can be even loss of vision. Quitting smoking is very helpful in improving patients outcomes. Patients with thyroid eye disease can be hyperthyroid, normal thyroid and even low thyroid. Control of systemic thyroid disease is important and is usually managed with the aid of an endocrinologist or primary care doctor.

The management of Graves Eye Disease is a combination of controlling the systemic thyroid dysfunction (if any) and protecting the health and function of the eye. The vast majority of patients will only have some eye irritation which can be handled with over the counter artificial tears and ointments. Some patients will not be able to close their eyelids at night and using a bland eye ointment in the eye prior to sleep can make the eyes feel comfortable and refreshed in the morning. Patients with blurry vision or double vision should be seen by Dr. Ahmad. Oral steroids (prednisone) is useful for short periods of time for patients with loss of vision and those with significant orbital congestion (eye socket will feel firm to touch or tender). Double vision can be handled with a prism on the glasses or a black patch to cover one eye.

In the acute setting of Graves Eye Disease surgical management is primarily orbital decompression in patients with vision loss or severe orbital congestion. Once the disease has stabilized, a surgical plan is put together in an individualized fashion. Some patients will require orbital decompression to move the eyes inward, eye muscle surgery to straighten the eyes, and finally eyelid surgery to improve the closing function of the lids as well as improve the cosmetic appearance. Dr. Ahmad will go over all these choice for you.

Surgical Procedures For Graves Eye Disease (That Dr. Ahmad performs)

Orbital Decompression

In Graves eye disease the orbital tissues which include the eye muscles and fatty tissue swell causing the eye to protrude outwards. The orbit (the bony cave which the eye sits in) is a tight space. Orbital swelling as in Graves Eye disease can cause pressure on the optic nerve which in a small percentage of patients can cause loss of vision. Orbital decompression is removal of bones around the eye giving the swollen eye muscles and fat space. This can improve vision and overall swelling around the eye.

Most patients with Graves eye disease will not have optic nerve compression (loss of vision) but may develop significant bulging of the eye. This is very often asymmetric with one eye being out farther than the other. If the bulging of the eye does not improve as the overall inflammation dies out, orbital decompression may be helpful to improve the cosmesis of the bulging.

There are three commonly removed walls in orbital decompresion, which include the lateral wall, floor of the orbit and medial wall. Sometimes only one wall is removed and other times multiple bones are removed. Dr. Ahmad will go over which bone or combination of bones would be helpful for your specific case.

The main risk of surgery is bleeding, infection, numbness and double vision.

Eyelid Retraction Surgery

The most common finding in Graves Eye Disease is eyelid retraction. This is when the upper eyelid is pulled over the colored part of the eye. This gives the patient a wide-eyed staring look. Retraction of the lower eyelid can occur as well. Eyelid retraction of the upper or lower eyelids can cause the patient to have eye irritation because of dryness of the eye. Some patients will not be able to close their eyes at night and will require drops or ointment prior to sleep. Many individuals with hyperthyroidism will see improvement in their eyelid position over time, especially when their hyperthyroid status improves. Some patients will not have improvement and will require eyelid surgery. Dr. Ahmad can surgically lower the upper eyelid so that the eyelid closure and irritation improves. He can also elevate the lower eyelids which may require a spacer graft often harvested from the patients hard palate. This can be combined with cosmetic blepharoplasty to remove some of the fatty tissue in the eyelids, smoothing out the appearance of the eyelids.

Blepharoplasty

Patients with Graves Eye Disease develop swelling of the eyelid fat pads and stretching of the eyelid skin. During the active phase of Graves Eye Disease the eyelids can be swollen and red. These findings usually improve over time in most patients. Some patients will require cosmetic blepharoplasty to improve the appearance of the eyelids. Removal of skin and fatty tissue can improve the puffiness of the upper eyelid. Removal of fatty tissue from the lower eyelid can help smooth the appearance of the lower eyelid. This may be combined with other procedures like eyelid retraction surgery