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Thyroid Eye Disease Surgery – Graves Eye Disease Surgery

What is thyroid eye disease / Graves eye disease?

Thyroid eye disease, or thyroid-related immune orbitopathy (TRIO), is often characterized by the bulging of one or both eyes. This disease can also cause the eyelids to retract (pull away from the eyes) and also cause the eyes to become misaligned (crossed).

This condition is also known as Graves’ disease. TRIO or Graves’ disease is caused by antibodies which affect your thyroid gland and at the same time cause muscles and fat behind the eye to become inflamed and push the eyes forward.

Contrary to popular belief, the thyroid gland actually does not directly cause this inflammation of the fat and muscles around the eye. In some cases, inflammation can compress the optic nerve, causing vision loss.

thyroid eye disease surgery before and after - female patient
THYROID EYE DISEASE/GRAVES’ DISEASE IN MIDDLE AGED FEMALE BEFORE AND AFTER CORRECTIVE SURGERY TO POSITION RIGHT EYE AND RIGHT UPPER EYELID.
THYROID EYE DISEASE/GRAVES’ DISEASE IN MIDDLE AGED FEMALE BEFORE AND AFTER CORRECTIVE SURGERY TO POSITION RIGHT EYE AND RIGHT UPPER EYELID.

What are the stages of thyroid eye disease?

  1. Inflammatory stage
  2. Fibrotic stage

The Inflammatory Stage

The inflammatory stage is when the eyes change and appear large, push forward, and can also appear red. This is when the bulging of the eyes can cause lower eyelids to pull down (lower eyelid retraction) and upper eyelids to become too open (upper eyelid retraction). There are continuous changes to the eye during the inflammatory stage, which can last from 2-5 years.

Asian Male in the inflammatory stage of thyroid eye disease in his left eye
MALE IN LATE 30S IN THE INFLAMMATORY STAGE OF THYROID EYE DISEASE IN HIS LEFT EYE APPARENT FROM BULGING.
Female with thyroid eye disease in the inflammatory stage
FEMALE IN EARLY 40S WITH GRAVES’ DISEASE IN THE INFLAMMATORY STAGE AFFECTING BOTH EYES CAUSING THEM TO BE TOO OPEN.

While this is the stage where the eyes appear their worst, surgery is not usually performed since the eyes are continuously changing. In special situations where vision is being threatened, surgery such as orbital decompression is performed.

Treatment during the inflammatory stage includes observation with no medical intervention, the use of steroids, and radiation therapy. Thyroid hormone levels are monitored by an endocrinologist. The thyroid hormone can be high (hyperthyroid), low (hypothyroid) or normal (euthyroid). In situations where the thyroid hormone levels are high, thyroid suppression drugs as well as radioactive iodine (RAI) can be prescribed by the endocrinologist.

How do I treat my eyes and eyelids affected by thyroid eye disease?

Thyroid eye disease also known as Graves’ disease or thyroid related immune orbitopathy are commonly referred to with the acronyms TED or TRIO can significantly affect the appearance of the eyes and eyelids I often see that people affected by this condition who are eager and highly motivated to improve their appearance with surgery as soon as possible it’s important to understand how this disease progresses and how the disease is managed in order to determine the optimal time to perform surgical procedures when indicated

I’m Dr. Amiya Prasad I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon I’ve been in practice in Manhattan and Long Island for over 20 years I’ve helped many people throughout my career with thyroid eye disease improve their appearance through different specialized procedures specific to the unique issues associated with thyroid related immune orbitopathy

Thyroid eye disease occurs when antibodies in your blood affect the thyroid as well as the tissues around the eyes for example inflammation from thyroid eye disease can affect the muscles and fat behind the eyes causing the eyes to bulge and protrude forward the upper and lower eyelids can also retract with or without the eyes bulging forward creating a staring type of appearance in terms of surgical correction it’s important to determine whether the thyroid eye disease is in an active inflammatory stage or a stable fibrotic stage the inflammatory stage is typically a time when the eye appearance is changing and the thyroid hormone levels are being managed by an endocrinologist medical management of the inflammation as well as the thyroid hormone can include interventions such as radioactive iodine steroid radiation therapy as well as medications to supplement or reduce thyroid hormone levels

This inflammatory stage can last two to five years surgery is usually not performed at this time unless there is a situation when vision is being compromised after the inflammatory stage is the fibrotic stage this period is characterized by the appearance of the eyes being more stable I confirm this by taking measurements of the relative prominence of the eyes using an instrument called an accelerometer as well as when appropriate slit-lamp examinations and of course taking clinical photos I routinely perform procedures to address the retraction of the eyelids as well as the changes in the skin and fat volume around the eyes there are times when thyroid eye disease can cause ptosis as well as laxity of the support structures such as the lateral canthal tendon for example I treat lower eyelid retraction with specialized procedures to raise the vertical height of the lower eyelid using a graft such as decellularized dermis

In addition I’ll perform a repositioning or reinforcement of the lateral canthal tendon using different methods of canthopexy or canthoplasty depending on the individual situation upper eyelid retraction can be addressed using procedures such as a removal of a muscle called Mueller’s muscle referred to as Muellerectomy I also perform procedures on the levator muscle the muscle which lifts or opens the eyes to allow the eyelid to move downward and use a graft material such as temporarily muscle fascia excess skin and fat can be addressed by more traditional cosmetic procedures such as upper and lower eyelid blepharoplasty however the relative prominence of the eyes and the inflammation that occurred does require in my opinion the unique skills and experience of an oculoplastic surgeon I regularly performed these eyelid restoration procedures under local anesthesia with LITE IV sedation so general anesthesia is avoided and my patients are comfortable and are able to return to work often in one week

I perform these procedures in my in office surgical facilities I do caution my patients with thyroid eye disease that there are some situations where the results may be challenging to achieve and secondary procedures may be necessary I’ve seen how tyroid eye disease can have a significant impact on a person’s facial appearance after the inflammatory stage has transpired and the eyes are stable in the fibrotic stage I work with my patient on a treatment strategy that best addresses their appearance with minimal risk I helped many of my patients restore their confidence and feel great about how they look after I performed their surgery

I hope you found this information helpful thank you for your question

The Fibrotic Stage

The fibrotic stage is when the disease has stabilized from the constant changes of the inflammatory stage. Stability is determined by measuring the relative position of the eye called exophthalmometry and other ophthalmic measurements.

In addition to examinations clinical photography is done to confirm the eyes’ stability in appearance. Once stability is confirmed, surgical correction of upper and lower eyelid retraction and repositioning of the eyeball can be planned.

male with Thyroid Eye Disease before and after correction surgery by Dr. Prasad
thyroid eye surgery before after

For some patients, surgical correction is not necessary as the eyes and eyelids can settle into a more natural position without medical intervention.

 

What is orbital decompression surgery?

Orbital decompression surgery is sometimes performed during the inflammatory stage to prevent vision loss. This is due to the potential of swollen eye muscles and fat from thyroid eye disease to put pressure on the optic nerve causing vision loss.

In these circumstances, orbital decompression surgery is used to create more room in the bony area around the eye, allowing the enlarged fat and muscles to shift.

This added space reduces the pressure on the optic nerve and allows the eye to be positioned further back in the orbit.

orbital decompression before and after
before and after orbital decompression surgery

Eyelid Retraction Repair – Upper and Lower Eyelid Blepharoplasty

Lower eyelids being pulled down, and upper eyelids being pulled upwards so the eyes are too open are common signs of thyroid-related immune orbitopathy (TRIO).

eyelid retraction surgery for thyroid eye disease before and after surgery
WOMAN SUFFERING FROM GRAVES’ DISEASE FOR ABOUT 2.5 YEARS HAD HER UPPER EYELIDS REMAIN TOO OPEN, SO DR. PRASAD PERFORMED UPPER EYELID REPAIR SURGERY TO GIVE HER A HEALTHY, NATURAL APPEARANCE.
eyelid retraction surgery for thyroid eye disease before and after surgery
WOMAN SUFFERING FROM GRAVES’ DISEASE FOR ABOUT 2.5 YEARS HAD HER UPPER EYELIDS REMAIN TOO OPEN, SO DR. PRASAD PERFORMED UPPER EYELID REPAIR SURGERY TO GIVE HER A HEALTHY, NATURAL APPEARANCE.

Restoration of eyelid position of upper and lower eyelids can be performed with limited surgery such as Mueller’s muscle resection and levator muscle myotomy or recession. It can also involve grafting tissue to increase the length of the retracted tissue. Procedures can involve the grafting of skin, temporalis fascia, Enduragen, hard palate graft, and decellularized dermis. Stabilization of the eyelid structure can involve procedures such as lateral canthoplasty, canthopexy and drill hole canthopexy.

Thyroid Eye Disease Surgery in New York

To better understand your options for thyroid eye disease treatment, schedule a consultation with Dr. Prasad by filling up the form below or calling any of our offices – (212) 265-8877 Manhattan, New York City or (516) 742-4636 Garden City, Long Island, New York.

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