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I Have Thyroid Disease – Can It Affect My Eyes?

Thyroid Disease can affect the body in many ways. Basically, either you produce too much thyroid hormone or not enough. Thyroid hormone is critical in maintaining many of the metabolic functions of the body, like temperature and activity levels. Usually, if you are making too much thyroid hormone, you are always warm and very hyperactive. Underproduction of thyroid hormone results in feeling cold, tired and sluggish. A very common type of hyperactive thyroid is called Graves Disease. Eye and eyelid findings are often seen in patients with Graves Disease (Figure 21). All patients diagnosed with thyroid abnormalities must have a thorough eye evaluation. Graves disease is five times more likely to affect women than men. Genetic factors appear to have a role in the development of thyroid associated orbitopathy, with 20%-60% of those affected reported to have a familial history of thyroid disease.
Environmental factors are also important in Graves disease. Cigarette smoking is capable of aggravating and prolonging thyroid-associated orbital inflammation.

What are the eye/eyelid findings seen with thyroid disease?
Dry, scratchy eyes are frequently present. This can be treated with topical lubrication both during the day and at bedtime. Eyelid findings include eyelid retraction, especially of the upper lid (Figure 22). With this sign, the upper eyelid is at a higher position than normal, causing the eye to appear too wide open. Another common finding is that the eyes can “bulge” forward. This, coupled with eyelid retraction, can give the very characteristic appearance of very prominent eyes. Usually this results in irritation and congestion of the eye. Treatment with tear drops and anti-inflammatory drops is frequently prescribed. If dryness and ulceration occur, infection is possible. These can be serious requiring urgent treatment. Sleeping with your head elevated often helps with the congestion.
Other less common signs include double vision caused by involvement of the muscles that move the eye.
A more serious situation can occur if there is compression of the optic nerve. This results from congestion and swelling of the eye muscles. This can cause permanent loss of vision. Optic nerve compression is considered a medical emergency. The severity and duration of the disease are unpredictable.
Radioactive iodine treatment for hyperactive thyroid has been reported to exacerbate preexisting orbital signs and symptoms. This is, however, somewhat controversial.

Besides the regular eye exam, what other testing is done?
Because vision loss from optic nerve compression is so important, I usually obtain a visual field test (a measurement of the optic nerve function), color testing (sensitive measurement of the optic nerve), and an MRI scan. The MRI scan actually images the optic nerve. The scan allows direct visualization of the optic nerve and can be used as a reference for future scans if the clinical situation warrants it.

What treatments are available for thyroid eye disease?
Fortunately, most patients with thyroid eye disease require symptomatic treatment only. That is tear supplements and lubricating drops. Most thyroid eye disease will run a course of a couple of years. The goals of therapy are to prevent ulceration, infection and loss of vision. Patient comfort is also a priority.
If optic nerve compression is present, treatment must be urgent. Cortisone by mouth, radiation and surgery are all options. Surgery consists of decompressing the tissues around the eye to relieve any pressure on the eye.

As mentioned above, all patients with thyroid disease need to have regular visits with the oculoplastic specialist. This will depend on the severity of the disease and the eye findings. I feel very strongly about constant communication with patients during this difficult time. Support for patients is vital for their care.

Can thyroid eye findings be present without obvious evidence of thyroid disease?
This concept gets a little tricky. The answer is yes. It is generally well accepted that some patients present to the eye doctor with eye/eyelid findings suggestive of thyroid disease. These were discussed above. However, when these patients are checked for thyroid disease by the standard testing, their thyroid values are normal. Also, they have no symptoms of systemic thyroid disease on routine testing.
I will usually recommend to these patients that they consult with an endocrinologist, a medical doctor who specializes in thyroid disease. An endocrinologist can perform more sophisticated blood studies that can confirm the presence of thyroid disease. Even if the studies are negative, patients with eye findings are categorized as having euthyroid eye disease. I follow these patients carefully with their endocrinologist and treat any eye disease as described above.

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