Is this ptosis and can it be cured?
I am 22 years old and noticed a recent change to my eyes where one looks significantly larger
than the other. The right eyelid has dropped, and the other seems to give off a 'staring'
and bulgy appearance. It's only become noticeable/this bad over the last few weeks. I went to the
doctor and was diagnosed with thyroid issues. I asked if this could be related, but she
didn't give me any info. I am now on medication and changed my diet completely. Will this
help my eyes? What can I do?
Thank you for your question!
You’re 22 years old and you described very well in detail with this one photo that you
submitted how one is drooping and the other is starting to bulging and staring. And that
you have seen your doctor and you were diagnosed with thyroid issues and you are on medication.
So I think that what you’re going to be learning about and what this appears to be
a situation called thyroid-related immune orbitopathy. Just to give you some background,
I’m a board certified cosmetic surgeon but with original training in eye surgery followed
by training in oculoplastic surgery which is surgery of the eyelids or the lacrimal
system. And we specialize in thyroid-related eye disease.
So the term that is typically used in our field is thyroid-related immune orbitopathy
or TRIO. Another term that is more commonly used is Graves' disease. What this disease
is caused by an autoimmune response that these antibodies that affect both the thyroid and
the soft tissue of the eyes. A lot of people believe that the thyroid is affected by either
by creating too much thyroid hormone called hyperthyroid. In this disease, you can have
high thyroid, low thyroid or hypothyroid or it can be normal thyroid or euthyroid. But
there’s often a misunderstanding that there’s a direct relationship between the thyroid
hormone and the changes in the eyes. It’s not the case. The thyroid and the eyes are
affected by the antibodies and what’s happening is, your endocrinologist will manage you with
either medication or may be even something called radioactive iodine to reduce the thyroid
depending on what happens on your thyroid hormones. The eye changes will occur regardless,
even if there has been some studies that have shown that when the thyroid level is very
high, the eye changes are worse. But a person can have very well controlled thyroid but
their eye changes can go on for years.
In general, the understanding is that most thyroid related immune disease is divided
in to two stages: one is called the inflammatory stage and the other is called the fibrotic
stage. The inflammatory stage is the stage you’re in right now where there are continuous
changes in the eye shape and the eye may push forward, the eye may become very red, the
eyes may retract and staring appearance will occur. But it’s a time of variability. And
there are a lot of different options of how to manage depending on how the eyes are affected.
Management options include nothing or observation, the use of steroids as well as the use of
radiation and this will be determined by you and your doctors as things develop.
When we talk about surgical options, we wait for the stage called the fibrotic stage. The
one exception of course is if the inflammatory stage occurs. The inflammatory stage is it
affects the muscles of the eyes as well as the fat around the eyes. It also affects the
eyelids. And that’s why the eyes can even not bulge out but the eyes can open and become
very retracted. During this inflammatory stage, like I said, there’s continuous changes.
There’s a time where the disease finally burns out and it becomes what’s called the
fibrotic stage. And that’s the stage when the appearance becomes more stable. Now the
time frame is, this inflammatory stage can last up to 5 years but in typical clinical
experience, it will last up to somewhere two years.
The way to determine stability is by doing measurements by the relative position of the
eye called exophthalmometry as well as continuous examination and photography to make sure that
your eyes are stable. Once it is stable, we have many different medical options such as
the treatment of eyelid retraction and the treatment of eye position. So there will be
options but there are many patients, just to balance this out, whose eyes don’t need
surgery. They will resolve to the point where if it’s known that you’ve had thyroid
eye disease, there’s no obvious signs. So it’s a wide spectrum. And then there’s
people on the other side who have very bulgy eyes or their eyes are crossed or they have
one retracted, one eyelid higher than the other. You know this is actually a disease
that affects a lot of people particularly women who tend to be younger and can be very
emotionally devastating. But you are in good company because a lot of people have experienced
this and I have been in practice for over 20 years so I have been through this process
with a lot of people.
It’s important that you continue to do what you’re doing with your medical doctors but
don’t be too eager to do surgery too early. Thyroid eye disease, the only true indication
that I’ve operated on for somebody was when their optic nerve or the nerve that supplies
their eyes was getting compressed or they were developing such exposure that the cornea,
the front of the eye was getting compromised. Otherwise, we try to avoid doing surgery until
the fibrotic stage. So I think you’re in the right track in terms of your research
but just don’t do anything too early or without consensus and the awareness that you’re
disease process has been stabilized.
So I hope that was helpful, I wish you the best of luck and thank you for your question!