Graves Disease treatment: What I do for my Colorado Patients
One of the most common causes of eye problems in patients is Graves Disease or Thyroid Eye Disease. For patients in Denver who have graves disease, an oculoplastic surgeon can correctly follow, monitor and treat patients with surgery. As an oculoplastic surgeon, I commonly see Graves patients. Graves disease is a difficult disease for patients and doctors. It is difficult because it is cosmetically disabling, difficult to treat and can have severe visual sequelae. This article is meant to be an intro to Graves Disease for patients.
What are the signs of Graves Disease?
Graves disease affects the eye socket in three manners. First it can cause eyelid retraction. Eyelid retraction is when the upper eyelid is elevated or rides high. The white of the eye is visible above the eye in the upper eyelid. Second, Graves disease can cause eye motility issues. In this case the eyes do not move correctly. This can cause double vision. Third, Graves eye disease can cause bulging of the eye or proptosis. In fact, graves eye disease is the most common cause of eye bulging in adults not only in Denver or Colorado or the US but the world. It is the most common cause of one eye bulging or both eyes bulging. Though these are the most common signs
What are the symptoms of Graves Disease?
First off, what is the first symptom of graves disease? The most common first symptom of graves disease is eye discomfort. Patients will feel pressure or “fullness sensation” in their eye socket. This pressure sensation will be worse in the morning and better at night commonly.
Secondly, patients will feel that their eyes are puffy and seek a cosmetic consultation for a blepharoplasty. Young female patients who present with puffiness of the upper and lower eyelids can especially have an early sign of graves disease. It is important to have this patient checked for graves disease instead of proceeding to a blepharoplasty.
Thirdly, double vision is one of the most common symptoms of graves disease. The double vision is worse in the morning and improves during the course of the day typically. The most common type of double vision is vertical double vision or seeing images on top of each other.
What causes Graves disease?
A common misconception is that graves disease is caused by problems with one’s thyroid. That is partially but not completely true. In essence there is an antibody or something in the blood that affects the eye and/or the thyroid. In some cases the antibody causes problems with the eye alone. Other times it only affects the thyroid. In some cases it affects both. Rarely, patients can have the antibody and it does not affect either the eye or thyroid. In the thyroid the antibody can stimulate or inhibit the thyroid causes an increases or decrease in thyroid function. In the eye, the antibody stimulates the production of fat and muscle which can cause bulging of the eye, double vision or eyelid retraction.
If Graves disease is not caused by the thyroid why are we checking it?
Though graves disease is not caused by thyroid dysfunction, thyroid dysfunction can cause the graves disease to be much worse. It is important to have your thyroid function stabilized to reduce the severity of the graves disease. Your endocrinologist in Denver can help do that. They have expertise in thyroid management.
Anything make Graves Disease worse?
Yes. The most important thing I tell patients is that Graves disease is made much worse in smokers. In fact, the course of the disease lasts 1 year in non smokers and 3 years in smokers. Smokers have much more severe disease and have a higher incidence of blindness. If you have graves I recommend immediately quitting smoking. In fact if you don’t have graves, I recommend immediately quitting smoking. In case you were frozen for the last forty years, smoking will age and kill you prematurely.
How do I know how bad my graves disease is?
Graves disease is catergorzied in many different ways. There are several studies that have graded the severity of Graves disease. The most common grading I use is the EUGOGO staging because it breaks down patients into three categories. Mild graves are just observed. Moderate to Severe Graves need suppression of immune system and Sight threatening Graves need surgery.
1.Sight threatening Graves – vision loss occurring via damage to optic nerve or cornea
2. Moderate to Severe Graves – lid retraction over 2 mm, exophthalmos over 3 mm, moderate soft tissue involvement, constant double vision
3. Mild Graves – lid retraction under 2mm, exophthalmos under 3mm, mild soft tissue involvement, transient or no diplopia
What is the treatment for graves disease?
There are four main paths of graves disease: Observation, steroids, radiation, and surgery.
If patients have mild graves disease (usually identified as just eyelid retraction) patients can be observed. With dryness of the eyes, eye drops can be used to lubricate the eyes during the day and at night.
Steroids have been used for a long time for graves disease. Steroids can be given in oral form (pill) or intravenous. Steroids carry with them many complications including blood sugar elevation, blood pressure rise, bone fractures, psychiatric issues. A landmark study to look at steroids in Graves disease was the EUGOGO trial. The study showed that sight threatening graves and moderate graves may benefit from 1-2 weeks of IV steroid treatment. It also showed that patients who were getting radioactive iodine could benefit from prophylactic oral steroids at the same time. Finally, steroid may be used in moderate graves patients in a pulsed fashion over several weeks. Giving 8 grams or more of steroids has been associated with death and it is avoided. Also, patients have to be screened for several diseases that can be made worse from steroids.
The best role for radiation from the EUGOGO trial is in patients who have quiet graves (not active) and have double vision.
A recent study in the Journal of the American Medical Association showed 100ug of selenium twice a day reduces the severity of graves disease.
There are three primary surgeries in graves disease: Orbital Decompression, Strabismus surgery for extraocular muscles, and Eyelid Surgery
Orbital Decompression: Orbital Decompression is best for patients who have proptosis or optic neuropathy. In this surgery, the eye socket bones are broken to give more space for the eye, nerve and fat to sit.
Strabismus Surgery: Eye muscle surgery is done for double vision. It is done after orbital decompression surgery.
Eyelid Surgery: Eyelid surgery is completed after strabismus surgery. It can be done to bring the eyelid down or tighten the lower eyelid.
These surgeries are best done once things are stable for 6 months. Stable means that the eye and eye socket has not changed at all. It is best to not perform surgery on a moving target.
Hopefully this is a good insight into graves disease for my patients in Denver. Thyroid eye disease c an be a very difficult and tough disease to have as a patient and to treat. We hope that through education we can help patients understand the disease and how to treat it.