Eye For God
Bert Bowden, MD
Cosmetic and Reconstructive Eye Surgery

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Thyroid eye disease

Thyroid-related ophthalmopathy is also known as Graves' disease or dysthyroid ophthalmopathy. It is a condition that is associated with changes in the thyroid gland that results in changes in the orbit. Actually, the most common involvement is of the muscles of the eye, and this results in a characteristic pattern of findings.

The most frequent finding in thyroid-related ophthalmopathy is that the muscles are involved and this results in proptosis or protrusion of the eyeball from the socket. Since it also affects the muscles of the eyelid, it can cause the eyelids to be more open resulting in retraction. These two things can lead to irritation of the eye and exposure of the eye, as the eyelids are unable to properly protect the eye. Of course, the lacrimal gland, which is within the orbit, can be involved by the thyroid-related ophthalmopathy. As a result of this the product of water tears is also affected.

Proptosis, retraction, and problems with tear production lead to tearing, the most commonly seen problem associated with thyroid-related ophthalmopathy patients.

Thyroid-related ophthalmopathy is also very frequently associated with smoking. It has actually been found that there are receptors within the eye muscles that are sensitive to cigarette smoke. These will swell and cause difficulties. If one is diagnosed with thyroid-related ophthalmopathy, one of the most important things to prevent further damage to the eyes is to stop smoking.

Treatment of thyroid-related ophthalmopathy involves four stages.

  • The first stage is routine medical care. This involves tears, ointments, taping the eyes if necessary, and all routine things that are done for all thyroid eye disease patients.
  • The second stage involves non-routine medical care. For patients with unusual problems we initially treat medically. We may use steroids, radiation, glaucoma medicines, and other medical treatment to protect the eye and vision.
  • The third stage of rehabilitation is routine surgical care. This is only undertaken after the patient has had 6 months of stability in their measurements that I make in the office. It, too, has 4 components:
    • Orbital decompression --moving the eyes back into the socket. This involves removing the bone around the orbit to allow the swollen thyroid eye muscles to go back into the sinuses. Up to 1/3 of patients may get crossed eyes from this.
    • Straightening the eyes (strabismus surgery)--this is for patients who already have crossed eyes or develop it after the first surgery. This involves loosening the medial or inferior muscles to allow the eyes to develop fusion.
    • Eyelid surgery --to lower the retracted upper eyelids or raise the retracted lower lids (particularly if they were made more retracted after strabismus surgery).
    • Blepharoplasty --to remove the excess fat and skin that are always created as a result of the thyroid eye disease.
  • The fourth stage of rehabilitation typically involves non-routine surgical care. This is reserved for those who do not respond to routine medical care and are losing vision, losing visual field, or suffering severe exposure problems. This may be an orbital decompression or just a tarsorrhaphy to protect the exposed eye. This is done only in very unusual circumstances to protect the eye and maintain the vision.


Patient 1 Pre-Operation



Patient 1 Post-Operation

Patient 2 Pre-Operation


Patient 2 Post-Operation



Patient1:  Image 1    Image 2    Image 3

Patient2:  Image 1    Image 2    Image 3


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