Thyroid Eye Disease Surgery
Thyroid Eye Disease Surgery
The thyroid gland, located in the neck, produces thyroid hormone which helps regulate our metabolism. It may occasionally produce too much thyroid hormone (hyperthyroidism or thyrotoxicosis) or too little (hypothyroidism or myxoedema). Imbalance in either direction can cause eye and vision problems. The precise cause of thyroid eye disease, which may be very variable in its manifestations, remains a mystery.
Thyroid Eye Disease Surgery
What are the symptoms of thyroid related eye problems?
A staring appearance and dry eyes are often the first symptoms. Early signs include swelling of the eyelids and tissues around the eye. The eyes can become red and the conjunctiva (the membrane covering the white of the eye) may swell giving a “jelly-like” appearance above the lower eyelids. Swelling of the fatty tissue surrounding the eye and the eye muscles can push the eye forward creating a protrusion of the eye.
The degree of protrusion is variable and may involve one or both eyes, adversely affecting the cosmetic appearance and causing irritation, photophobia and watering of the eyes. Swelling of the muscles which move the eyes may produce double vision. In severe cases, the clear covering of the eye (the cornea) may ulcerate, or the optic nerve may be compressed resulting in loss of vision if not treated appropriately.
Can thyroid eye disease occur even if thyroid function tests are normal?
Protrusion and other symptoms and signs of thyroid eye disease may be present even when tests show a normal level of thyroid hormone in the blood. Most patients with eye symptoms, however, have abnormal blood levels of thyroid hormone.
How is thyroid eye disease treated?
Once an overactive thyroid gland is suspected, the thyroid function must be evaluated and appropriately treated by an endocrinologist (a medical doctor or physician who specializes in the treatment of problems with the thyroid gland as well as diabetes and pituitary disorders). The eye disease may continue to progress even after the thyroid function has been corrected. Any eye problems should be followed and, and, if necessary, treated by an ophthalmologist.
Two phases of eye treatment should be considered. The first phase involves treating the active eye disease. The active period, which usually lasts two or more years, requires careful monitoring until stable. The second phase involves correcting unacceptable permanent changes which persist following stabilization of the active phase.
Treatment during the active phase of the disease focuses on preserving sight, and treating or preventing double vision. Medical treatment, such as artificial tears and ointments, steroids (usually given intravenously on an inpatient basis), orbital surgery, and possible radiation (X-ray treatment) of the orbit, may be required. In the second phase, treatment of permanent changes may require surgical correction of double vision, eye protrusion, eyelid retraction and “eyebags”.
With rare exceptions, surgery for thyroid eye disease is performed in the following sequence (although not every stage is required by most patients):
- Orbital decompression
- Eye muscle (strabismus) surgery
- Eyelid repositioning surgery
What is an orbital decompression operation?
An orbital decompression operation is a surgical procedure undertaken to create more space in the orbit. Read more about Orbital Decompression.
- Strabismus surgery
Surgery to deal with double vision is only undertaken when the deviation of the eyes has remained stable for a period of 6 months. Whenever possible, temporary stick on prisms are fitted to glasses to overcome double vision until surgery is deemed appropriate. This surgery is performed by other colleagues who specialize in strabismus (squint) surgery. We highly recommend Mr Ian Marsh, Consultant Ophthalmic Surgeon in Liverpool who has over 20 years of experience in such surgery.
- Eyelid repositioning surgery
Upper and lower eyelid retraction may be treated by lengthening the tendons of the eyelid retractor muscles. This is often performed via an incision on the side of the eyelids, avoiding an external scar. This is usually performed under “twilight anaesthesia” for the upper eyelids. This allows greater accuracy to be achieved with regard to the final height and contour of the upper eyelids to achieve the best cosmetic result. Nevertheless it may be very difficult to achieve symmetry and to avoid a flaring of the outer aspect of the upper eyelids.
Complications of such surgery include an under or overcorrection of the degree of retraction requiring further surgery. Lower eyelid retraction may be treated by means of grafts taken from the hard palate (roof of the mouth) usually under general anaesthesia, or using dermal grafts (taken from the lower outer quadrant of the abdominal wall or buttock area). Often lower eyelid retraction surgery is not required in patients who have undergone an orbital decompression as the lower eyelid retraction often resolves following such surgery. Upper lid retraction responds occasionally but less predictably.
What are the risks of eyelid repositioning surgery?
The risks of eyelid repositioning surgery include infection, bleeding and reduced vision, but these complications occur very infrequently. A temporary inability to fully close the eye after surgery is not uncommon. Lubricant drops and ointments are frequently useful in this situation.
It is also important to know that although improvement of the lid height is usually achieved, perfect symmetry in the height and contour of the two eyelids and full eyelid movement is sometimes not achieved. More than one operation is occasionally required.
What happens after eyelid repositioning surgery?
You will be asked to clean the eyelids and repeat the application of antibiotic ointment to the eyelid wound 3 times a day for 2 weeks. The sutures used are usually dissolvable but can be removed after 2 weeks if necessary. Wearing make-up should be avoided for at least 2 weeks. Postoperative bruising usually takes 2-3 weeks to subside. The upper eyelid is often too low initially following surgery, but rises gradually with time. Postoperative swelling may take a few weeks to subside and the final result of surgery is not usually seen for 3-4 months. The upper eyelid scar following a levator recession is hidden within the upper eyelid skin crease. Occasionally the surgery is performed on the inside of the eyelids leaving no visible scars.
Severe eyelid swelling in thyroid eye disease may leave the eyelids with a very “baggy” appearance and with excess skin and fat pad prolapses. Blepharoplasty, a cosmetic eyelid surgery operation, involves the removal of excess skin and fat from the lids. This may improve the appearance of the lids but cannot restore normality. This type of surgery for a patient with thyroid eye disease is much more challenging than similar surgery undertaken for cosmetic reasons alone.
Thyroid Eye Surgery
You will visit the clinic to have a preoperative consultation with your surgeon. This usually lasts 30-45 minutes. You will be asked to complete a healthcare questionnaire, providing information about:
- Your specific aims
- Your current and past general health
- Any previous eye, eyelid or facial surgery or treatments including refractive surgery or laser eye surgery
- Any past dermatology history e.g. cold sores, eczema, rosacea, skin cancer
- Any history of a dry eye problem
- Any contact lens wear
- Any previous non-surgical aesthetic treatments e.g. Botox injections.
- Any allergies
- Any medications you take (including over the counter products e.g. Aspirin, Indomethacin, Nurofen, Diclofenac or vitamin supplements)
- Any history of smoking
It is very helpful if you have old photographs which you can bring along to the consultation. If you are happy to email us digital photographs of your current appearance in advance of the consultation with details of your concerns, this is also enormously helpful and saves time. Your photographs will be kept confidential and will form part of your clinical record.
- You will have your blood pressure checked by the nurses. You may also be required to have a physical examination of your heart and lungs by the anesthetist to make sure it is safe for you to have a general anesthetic if this is required in your case. You may need to have some routine laboratory tests, such as urinalysis (tests of your urine), a chest x-ray, or a blood cell count. These should reveal potential problems that might complicate the surgery if not detected and treated early. No testing is usually necessary, however, if you are in good health and younger than age 55.
- The nurses are also happy to answer any further questions and to show you the facilities at Face & Eye, including the operating theatre if it is not in use.
- Please answer all questions completely and honestly as they are asked only for your own wellbeing, so that your cosmetic surgery can be planned as carefully as possible. The information is treated confidentially. If you are unsure of the names of any medications, bring them with you.
- You will be told whether or not to stop any medications at this preoperative clinic visit. For example, if you are taking aspirin-containing medicines or anticoagulants, they may need to be temporarily withdrawn or reduced in dose for two weeks before the procedure as long as these are not medically essential. You might need to check this with your GP. Any anti-inflammatory medicines e.g. Ibuprofen, Nurofen must be discontinued at least 2 weeks before surgery. These medicines predispose you to excessive bleeding. You will be given a leaflet advising you on what medications, foods, and vitamin supplements to avoid prior to surgery. Your blood pressure should also be under good control if you take medications for hypertension. This is very important.
- If you can, try to stop smoking at least six to eight weeks prior to surgery. Smoking has an adverse effect on healing and damages your eyelid skin and supporting tissues and your eyes (it can result in premature cataract formation and age related macular degeneration with a loss of central vision). Smoking also makes thyroid eye disease considerably worse.
- Your vision in each eye is measured. Your eyes are examined carefully using a slit lamp (a special ophthalmic microscope). Your tear film status is determined and the back of the eyes (called the retina) are examined as well as the eyelids themselves.
- The rest of your face is then examined. Photographs of your face and eyelids are taken before surgery so that the results of surgery can be compared with the original appearance. The photographs are confidential and can only be used for any purpose other than your own records with your specific written permission.
- All our patients are provided with a detailed report following a consultation. This summarizes the consultation, the recommendations and also the preoperative and postoperative requirements.
- We much prefer that our patients return to see us in clinic before proceeding with their surgery so that we can have the opportunity to answer any queries and so that a consent form for surgery is completed in advance and not on the day of surgery. If a patient is traveling a long distance however, this second consultation can be omitted and instead queries can be addressed by email and a copy of the consent form sent in advance so that this can be checked by you.
- What are the possible complications of thyroid eye disease surgery?
Complications in the hands of a trained and experienced oculoplastic surgeon are very rare and all precautions are taken to minimize any risks.
Most complications of eyelid surgery are amenable to successful treatment.
Complications from cosmetic eyelid surgery include:
- Blurred or double vision, lasting mainly for a few hours, and sometimes up to a day or two after surgery. This may occur for several reasons – ointment put in the eyes immediately after the operation, local anaesthetic used in the operation, swelling of the muscles that control eye movement or swelling of the normally clear covering around the eye (the conjunctiva). Swelling of the conjunctiva (this may mimic a severe hay fever reaction) is referred to as “chemosis” and in some patients can take a few weeks to resolve. If blurring persists for longer than 48 hours, it is important to inform your surgeon.
- Watery eyes – this is quite common for the first few days after the operation due to some irritation of the eyes and a temporary weakness of reflex blinking of the eyelids.
- Dry eyes may persist for two to three weeks or sometimes longer. You will need to lubricate your eyes every 1-2 hours using artificial tears during the day (e.g. Hyabak drops, Hylotears, Viscotears, Systane drops) and an ointment at night (Lacrilube). These should be prescribed for you. You will gradually reduce the frequency until you can dispense with them altogether. It is very rare for patients to have to continue with them long-term but this is possible. This is why it is important to exclude a dry eye problem before proceeding with this type of surgery.
- Injury to the surface of the eyeball (a corneal abrasion) that causes persistent pain. If the pain lasts longer than a few hours after the operation, the surgeon must be informed. Such a problem is extremely rare in the hands of an oculoplastic surgeon. Such a problem is treated with antibiotic ointment. Sometimes a bandage contact lens needs to be used.
- Bleeding. A collection of blood around the eyelids or behind the eyeball, is called a haematoma. A sudden haematoma behind the eyeball can cause loss of eyesight if not managed appropriately and without delay. This is the most serious potential complication of this surgery but is extremely rare. An oculoplastic surgeon is trained to prevent and to manage such a problem. A haematoma usually needs to be drained in the operating theatre.
- Damage to the muscles that move the eyeball (e.g. the superior rectus muscle from the use of cautery to seal a bleeding blood vessel adjacent to the muscle) causing double vision is an extremely rare problem and this usually resolves by itself with time. In the very unlikely event that double vision were to persist, a referral to another ophthalmic surgeon with expertise in the management of eye movement disorders and possible further surgical intervention would be required.
- Exposure of the cornea, the clear sensitive surface of the eye. When blinking the eyelids do not cover the eyeball completely. This often occurs for a short time after the operation and is treated routinely with artificial tear drops. If too much skin is removed from the upper eyelids, the eyelid closure can be compromised long term. This may require further surgery to correct it. For this reason, great care is taken to mark any skin to be removed before surgery is commenced. Such a problem is very unusual in the hands of an oculoplastic surgeon.
- Acute glaucoma – this is raised pressure within the eye, which results in pain in the eye, haloes around lights or severe blurring of vision, a headache above the eye, and vomiting. A patient at risk of such a postoperative problem would be identified by an oculoplastic surgeon. An oculoplastic surgeon is trained to diagnose and treat such a problem.
- Infection. An infection following this surgery is extremely rare but it is important to follow postoperative wound care instructions to help to prevent such a problem. These should be given to you in writing for you to take home following surgery.
- Asymmetry. It is impossible for any surgeon to achieve perfect symmetry although an oculoplastic surgeon strives to achieve this. A cosmetically unacceptable asymmetry e.g. of the upper lid skin crease, fullness of the eyelids, lower lid position is always possible and further surgery may be required to address this.
- Scarring. Most eyelid wounds heal with scars that are barely perceptible although full maturation of the wounds can take some months. Poor scarring can follow infection or wound disruption but this is very rare. Poor scars can be treated with steroid injections or with the application of silicone gels e.g. Kelocote. Rarely, scars need to be revised surgically.
- Eyelid lumps. Lumps can very occasionally occur as a reaction to sutures used to close the wounds. These usually resolve with time but occasionally steroid injections are required. Rarely, lumpiness can occur in fat that is repositioned over the inferior orbital margin. This usually responds to postoperative massage.
- Reoperation. Further surgery within the first few weeks to address any asymmetries may be required. This should be borne in mind. There are a number of factors beyond a surgeon’s control, which can have an impact on postoperative progress e.g. postoperative swelling affecting one side more than the other, which in turn can necessitate re-intervention.
What are the possible complications of orbital decompression surgery?
Serious complications from orbital decompression surgery e.g. loss of vision, CSF leak (leak of brain fluid), meningitis, are extremely rare. The major potential complication, which must be considered, is postoperative double vision. The incidence of this complication varies considerably from surgeon to surgeon. It is much more of a problem in patients who have some double vision prior to surgery with a risk of up to 30% that this may be worse postoperatively. In patients with no pre-existing double vision, the risk is considerably reduced (<5%). It is rare for any patients who suffer this complication to be left with a significant problem following corrective eye muscle surgery. This risk must, however, be considered very carefully in a patient who wishes to improve cosmesis as this has implications for driving and work. It may be necessary to wait for some months before muscle surgery can be undertaken to improve double vision. In some patients temporary prisms can be fitted to glasses to improve double vision. Our patients are referred to Mr Ian Marsh in Liverpool. He is a recognized expert in squint surgery with over 20 years experience as a consultant ophthalmic surgeon.
Other potential complications which should be considered:
- Loss of sensation in the cheek, side of the nose and front teeth, and in the temple (this usually recovers after a few weeks or months)
- Retraction of the lower and/or upper eyelid
- Reoperation. Further surgery to address any asymmetries may be required. This should be borne in mind. There are a number of factors beyond a surgeon’s control, which can have an impact on postoperative progress e.g. postoperative swelling affecting one side more than the other, which in turn can necessitate re-intervention.
What happens after thyroid eye surgery?
After thyroid eye disease surgery, the eyes are initially covered with pressure dressings for approximately half an hour to reduce postoperative swelling and the wounds are treated with antibiotic ointment. The dressings are then removed and replaced with cool packs. Activity is restricted for 2 weeks to prevent bleeding.
You will be asked to clean the eyelids very gently using clean cotton wool and Normasol (sterile saline) or cooled boiled water and repeat the application of antibiotic ointment (usually Chloramphenicol or Soframycin) to the wounds 3 times a day for 2 weeks. The sutures used for a levator aponeurosis advancement are dissolvable but are usually removed in clinic after 2 weeks. The sutures used for a Muller’s muscle resection are removed in clinic after 5-7 days.
The skin around the eyes should be protected from direct sunlight, by avoidance if possible or by using protective sunglasses. Wearing make-up should be avoided for at least 2 weeks. After 2 weeks the use of mineral make-up is recommended. (The aesthetics nurses at the clinic Face & Eye can demonstrate this to you). It is important to devote a lot of time to your aftercare for the first 2 weeks and some patients find this somewhat labour intensive.
A realistic period of recovery must be expected. Postoperative bruising usually takes at least 2-3 weeks to subside completely. Swelling takes much longer. Most of the swelling disappears after 3-4 weeks but this can vary considerably from patient to patient as does the extent of the swelling. The final result is not seen for at least 3-4 months. This should be taken into consideration when scheduling the operation. You should arrange this surgery after holiday periods or important professional or social events and not before so that you are available for postoperative review and just in case any surgical adjustments are required.
The scars gradually fade to fine white marks within a few months. Those in the upper eyelid are hidden within the skin crease unless an additional skin incision is required to remove a “dog-ear” of excess skin just below the tail of the eyebrow.
You will need to use frequent artificial tears for the first 2-3 weeks following surgery. It is preferable to use preservative free drops. These will be prescribed for you e.g. Xailin gel (or Theoloz Duo drops, Hyabak drops or Hylotears), and Xailin Night ointment (or Lacrilube or Vitapos ointment at bedtime).
You are advised to sleep with the head raised approximately 30 degrees. It is preferable to raise the head of the bed if possible.
Contact lenses should not be worn for a few weeks following this type of surgery.
Conscious sedation, also known as “twilight anaesthesia”, is a type of anaesthesia which is preferred by many patients for most of my surgical procedures. It is a very comfortable and gentle type of anaesthesia which is far less invasive than the typical general anaesthesia but at the same time highly effective. It is also of advantage for very nervous or anxious patients undergoing quite minor procedures. Typically patients sleep most of the way through their procedure and have no or very little recollection of it at all. You are looked after throughout the procedure by a specialist consultant anaesthetist who has many years of experience of this type of anaesthesia, so that your surgeon can concentrate fully on your operation.
Shortly before moving to the operating room, a small tube (cannula) is placed into a vein in the back of your hand by the consultant anaesthetist and the anaesthetic drug is given through that. This is Propofol, a drug which is also used for general anaesthesia but, for conscious sedation, much lower doses are used. With conscious sedation there is no breathing tube or breathing machine, just a gentle flow of oxygen given through a plastic tube within a soft sponge protector inserted into one of your nostrils. Once the sedation has been commenced a local anaesthetic solution (a mixture of Marcaine and Lignocaine) is injected into the operative area to ensure a painless procedure. Typical side effects of general anaesthesia including a sore throat and nausea are avoided. Waking up takes only a few minutes at the completion of the surgery and is usually free of any “grogginess.” This type of anaesthesia has been used safely and successfully for our surgical procedures for over 20 years.