Graves' Disease Shows Up in Your Eyes

Graves' disease is an autoimmune disease which affects the thyroid.  It causes heart palpitations, mood swings and hair loss; sometimes for women, it can make their eyes bulge. Now, there is a surgical solution for patients.

Graves' disease caused Tracy Farrow's thyroid to be overactive. It also caused enlarged muscles and fat behind the eye.

Farrow told Ivanhoe, "My eye lashes came all the way up past my eyebrow, so my eye was just very big."

It looked bad, it hurt, and it threatened Tracy's eyesight.  Now, she is back to normal thanks to an advanced surgical approach. 

Grant Gilliland, MD, Oculoplastic & Orbital Surgeon at Baylor University Medical Center in McKinney, Texas told Ivanhoe, "We'll actually take this outer part and remove it, and that way we create what we call a balanced orbital decompression."

Using a CT scan as a guide, an oculoplastic surgeon goes in on one side and an ear nose and throat surgeon goes in through the sinuses. They clear out enough space for the eye to move back into the socket.

"We've even had some patients that were completely blind that we've done this procedure on and gotten their vision back to 20/20," Dr. Gilliland said.

This technique has shown to improve outcomes by reducing double vision, reducing pain, improving sight and improving appearance.

Amol Bhatki, MD, Otolaryngologist/ENT Surgeon at Baylor University Medical Center in McKinney, Texas said, "The best part of it is that we can do it in a way that they get a good outcome and don't have to have future issues, and they can get back into work and get back into their normal lifestyle pretty quickly."

Farrow exclaimed, "It's really a miracle what all they can do." Helping people like Tracy get their eye health and confidence back.

The procedure is covered by most insurance companies including Medicare.

Contributors to this news report include: Cyndy McGrath, Supervising Producer; Don Wall, Field Producer; Cortni Spearman, Assistant Producer; Jamison Koczan, Editor and Mikon Haaksman, Videographer.

BACKGROUND: In the U.S. an estimated three million people have Graves' disease. Graves' disease is a disease that causes an increase in thyroid hormone. It's most common in women and before the age of 40, but can occur in anyone. The symptoms include anxiety, weight loss, bulging eyes, enlarged thyroid gland, heat sensitivity, and a tremor in the hands and fingers. In Graves' disease, the body produces an antibody to one of the cells in the thyroid gland. The binding of this antibody then causes more thyroid hormone to be produced. Treatment for Graves' includes radioactive iodine therapy, beta blockers, anti-thyroid medications and surgery. Smokers are more likely to develop Graves' disease than nonsmokers.  

GRAVE'S OPTHALMOPATHY: Up to 80 percent of Graves' disease patients develop eye symptoms, a condition known as Graves' opthalmopathy. However, 10 percent of those diagnosed with Graves' opthalmopathy do not have Graves' disease. Graves' opthalmopathy affects the extraocular muscles, which move the eyeball up, down and side to side. The symptoms include dry eyes, double vision, bulging eyes, light sensitivity, excessive tearing and difficulty closing the eyes. Graves' opthalmopathy patients have an increased risk of developing glaucoma. Ointments may help reduce eye swelling and dryness. Medications, such as corticosteroids, may also be used to reduce inflammation.  

NEW TECHNOLOGY: In serious cases of Graves' opthalmopathy, surgery may be required. Often times, patients undergo a series of surgeries to correct the problems. First is the orbital decompression surgery, where they remove the bone tissue to clear space for the inflamed muscle and eye. This surgery also improves vision. The second step would be surgery on the eye muscles to realign them. In this step, muscles at the back of the eye are cut and re attached further back on the eye. Because the disease causes the eyelids to open wider than usual, another surgery to reposition the upper lid may be performed as the third part of the series.  

Grant Gilliland, M.D., Oculoplastic and Orbital Surgeon at Baylor University Medical Center and Amol Bhatki, M.D., Ear, Nose and Throat Surgeon and Director of Skull Base Surgery at Baylor University Medical Center talk about a rare disease that can affect the eyes.

Interview conducted by Ivanhoe Broadcast News in April 2015

Can you explain this particular case and how the thyroid could affect something in the eye?

Dr. Gilliland: There's a small subset of patients that have thyroid disease, either hyperthyroid where it's too high, or hypothyroid where the hormone level is too low. They can subsequently develop eye disease. We think it's from protein and immune globulins, or specific types of protein, deposited in the tissue behind the eye. It causes problems because of that deposition. Problems can be as severe as vision loss, including blindness. It can be less severe like dry eye or glaucoma in the eye from the pressure. It can even be mild with no vision problems, but just an asymmetric prominence of the eyes.

Due to the complications of the disease, does the tissue build up around the eye?

Dr. Gilliland: Yes. Tissue builds up in the fat behind the eyes. The eye socket is filled with fatty tissue. There are also six muscles that move each eye and the swelling builds up in those muscles. There's a propensity for the swelling to occur in two of the muscles more than the other four muscles. That can cause double vision because those muscles are asymmetrically swollen.

If it has no place to go, does it start growing out of the eye socket?

Dr. Bhatki: Yes. The eye socket is surrounded by bones on all sides except the outer side. As the tissue gets more and more enlarged within the eye socket, the only way to displace that is for the eyeball itself to move forward and that causes the prominence that Dr. Gilliland is talking about. That results in a lot of the symptoms that the patient is experiencing.

Is there a particular name for this syndrome?

Dr. Bhatki: The overall condition is called thyroid eye disease, but when the eye sticks out, it's called proptosis.

Can you describe what you actually perform in surgery?

Dr. Bhatki: It's a combined procedure. It's important to understand that the eye socket has various parts to it. There's the outer part and the inner part. The inner part of the eye socket is right up against the nasal cavity. We use that to our advantage to go in through the nasal cavity, open up the sinuses, similar to someone having sinus surgery. We use that corridor and get access to the inner part of the eye socket to decompress it. That's my role in the surgery.

Dr. Gilliland: After Dr. Bhatki has removed the inner part; we actually take this outer part, or thin bone through the nose, and remove it. We create what we call a balanced orbital decompression, meaning the soft tissue and the muscles are allowed to prolapse into the medial part of the nose where Dr. Bhatki has worked. Then, we put this boney rim back, but leave a deep hole here and a hole there. The way we've done this has decreased the complication rate. The old fashioned way of doing this operation had a thirty three percent chance of double vision after surgery. The incidence with a balanced decompression in the method that we do is less than five percent. It's made a big difference in patient outcomes.

Is this something revolutionary? Something that typically hasn't been done before?

Dr. Gilliland: It's a modification of procedures that's been done. As the years have gone on, the procedure has improved. We utilize surgical navigation that allows us to know exactly where we are during surgery. It is essentially a high tech computer that maps the patients face to the CT scan and allows us to take a pointer and know exactly where we are in surgery. We also utilize pre-operative planning. With this model and computerized planning, we can segment out which parts of the bone we're going to remove and try to predict what their post-operative result is. If we measure how prominent their eye is and want to predictably move their eye back a certain amount, and then we can plan that on the computer model beforehand.

Would you call this a medical breakthrough or just development through technology?

Dr.Gilliland: A little bit of both. We're utilizing technology kind of in a unique way that wasn't really by the companies that manufactured and invented this technology. They didn't foresee utilizing it in surgery. We've taken it and tailored it to this surgery both with the team approach and utilizing the technology to give the patients the best results.

Dr. Bhatki: Doing it in a balanced way is really important. If you take off more on one side than the other, the eye will tend to list inwards. If you take more on the outer side than the inside, the eye will tend to list outwards. So, doing it so that both surgeons are working together and have the teamwork and ability to kind of look at what each other is doing to match the decompression equally, allows their eye to stay forward and minimize the chance of getting double vision afterwards.

Can you talk about what kind of outcomes you're getting?

Dr. Gilliland: We've actually formally looked at outcomes and the first hundred and fifty patients that we've done, we found the average improvement in vision was two lines. So, when a patient reads the eye chart, they can read two lines lower on average after this procedure than before the procedure. We've even had some patients that were completely blind that we've done this procedure on and got their vision back to twenty/twenty. That's the most important thing. The second most important thing is the amount of reduction and prominence of the eye, or we call proptosis. We're able to reduce the amount of proptosis up to even twelve millimeters, which is unheard of in previous techniques before. We obviously grade that to the patients. That's where the pre-operative planning comes in.

Does that level of change in a person's appearance make a big difference for them?

Dr. Gilliland: Huge. Not only from an aesthetic standpoint, but also just from a functional standpoint. When patient's eyes are sticking out and prominent, they feel a pressure sensation behind their eye that they can never get away from. When we do this procedure, it eliminates that.

How many people that have this problem could benefit from it?

Dr. Bhatki: Graves' disease is not very common and is found more commonly in women than men. Only a fraction of them will develop orbital disease. So, it's a relatively small population of people that have it. The ones that do have a tremendous amount of discomfort and compromise in their quality of life. There's one patient who was a mechanic and used to work on transmissions and was having a difficult time rebuilding transmissions because of his vision. He did really well afterwards and now he's back at work. So, for him the appearance didn't matter, he was a tough guy. The pain didn't matter so much but he needed to work he needed to provide for his family. And, that's something that he values.

In addition to the aesthetics and the reduction of pain, are you getting better outcomes with vision?

Dr. Gilliland: Yes. The visual acuity improves on average two lines on the eye chart. For us and for the patients as well, the incidence of double vision is significantly lower than with older treatment modalities. It saves the patient an extra operation. They're less likely to have double vision after surgery, so it makes them rehabilitated faster.

The fact that you work as a team, does that reduce procedures and reduce anesthesia, does it mean that you get it done quicker and you recover quicker?

Dr Bhatki: It's good to work together because we can see what each other is doing. It is easier for me to do my part when I can see Dr. Gilliland and some of the problems that he's encountering. The other thing about it is you develop a collaborative technique. Things continue to get better over time and that only works with people coming together and developing new ideas and trying things out. From the patient's perspective, it ends up being one surgery for every eye that we do. As far as time and efficiency goes, the best part of it is we can do it in a way that they get a good outcome and don't have to have future issues and get back in their work and get back in their normal lifestyle pretty quickly.

Are you pretty happy with the long term results you're getting?

Dr. Gilliland: Yes. We have up to fourteen years with this procedure and essentially once you fix the patient, they're finished. This is a life-long treatment for them and they never have to have it done again. Patients have been very happy with that.

Is there anything else you would like to add?

Dr. Gilliland: It's a unique collaboration where ocular plastic surgery and skull based ear, nose and throat surgery works together along with high tech technology in order to improve patient outcomes. We're constantly looking how to improve and how to get better results and have good follow up on young, healthy patients that are debilitated in many cases by this disease.

Are most of these patients younger?

Dr. Gilliland: Yes. Typically, the average age hits females in the early forties.

Dr. Bhatki: Another thing that's important is that although it's a relativity infrequent occurrence, physicians see this and it's important for them to know that there's a surgery out there that can fix it. No one wants to have surgery and even a patient that's experiencing this is not eager to have it done, especially in a delicate place like around their eyes. But, when you accumulate the issues that they have and know that there's a solution out there that can help and put them in a place where they're able to recover quickly and use their vision the way they want to, it's important to know and understand that.