Graves Eye Disease and Surgery during the Inflammatory Period: When is it needed?
Graves Eye Disease is a disease characterized by inflammation in the eye socket. Particularily it affects the eye muscles and fat of the eye socket. Often this increases the production of fat and muscle resulting in swollen muscles of the eye socket and increased fat. In turn, that can cause bulging of the eye, eyelid retraction and double vision. Often patients in my offices in Denver and Littleton ask about when the timing of surgery is correct for Graves disease. As a Graves disease specialist it is critical to understand the proper timing and indication to perform surgery for these patients.
When is the best time to perform surgery on the eye for graves disease?
There are three key things to know about surgery in graves disease.
1. Orbital Decompression surgery is performed urgently for visual loss.
Occasionally, we can perform surgery to bring back the bulging eye into the correct position. These tests to determine if the optic nerve is being compromised are done in the office of your local eye doctor. From those procedures, one can tell if there is an optic nerve damage from Graves disease. In those cases where there is vision loss in Graves disease, an orbital decompression can be performed.
2. Without vision loss, we do not perform surgery for Graves disease unless things are stable for 6 months.
Graves disease has a course of roughly 1 year in nonsmokers and 3 years in smokers. As a result, bulging of the eye, double vision and eyelid position changes can vary and fluctuate until the disease is stable. Oculoplastic Surgeons certified from the American Society of Ophthalmic Plastic Surgeons (ASOPRS) do not perform surgery on the eye socket or eyelids for graves patients unless their exam is stable for six months. The reason for this is simple. Things can be changing. As a result if surgery is done immediately, the patient may need further surgery if things are not stable. This is confirmed with an exam every six months that includes:
Hertel Exam (To examine bulging)
Motility Exam (To determine eye muscle function)
This would be considered standard of care in graves disease surgery. Many patients want surgery “as soon as possible”. To succumb to this as a surgeon is a mistake. Doctor in latin means “teacher” and our role is to educate our patients as to the safe and correct path for success with surgical treatment of graves disease.
3. The order of surgery for Graves eye disease is eye socket, eye muscle and eyelid.
In Graves disease orbital decompression can cause/worsen double vision and eyelid position. Eye muscle surgery can worsen eyelid position. As a result we havea very specific order for surgery. We first do the orbital decompression, followed by eye muscle surgery and finally eyelid surgery. The reason is that we don’t want to do orbital decompression and eyelid surgery, only to have to do eye muscle surgery and then eyelid surgery again. This is not in the best interest of the patient. I reserve cosmetic procedures for graves disease after medical portions of the disease such as bulging of the eye, double vision and eyelid retraction and taken care of first. After those are taken care of, one can have blepharoplasty or cosmetic surgery .This is the standard of care protocol for Graves disease in Denver, Colorado and the United States.
Graves disease can be a debilitating and devastating eye disease to have. With the lead of an oculoplastic surgeon, ophthalmologist and endocrinologist it is possible to return to normal function and appearance. In my office in Denver we treat Graves eye disease patients commonly and often have them return to normal function over time. Also of note, steroids and radiation play an important role in the disease and can help patients sometimes better than surgery. An oculoplastic surgeon with a comprehensive understanding of treatment of the disease is necessary for the optimal outcome.