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Thyroid eye disease
Thyroid eye disease
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Thyroid eye disease (thyroid orbitopathy or TO) is a condition of inflammation and engorgement of the soft tissues surrounding the eyes.
How the eye works
We need light to see what is around us and to see colour. Light bounces off the objects we look at. These reflect different amounts of light which we see as different colours.
Light rays enter the front of our eye through the clear cornea and lens. It is very important that both the cornea and lens are clear as this allows the light to pass directly through the front of the eye to the retina. The cornea and lens bends light so that it can focus on the retina at the back of our eye. This gives us a clear, precise image. The cornea focuses the light towards our retina. The lens fine tunes the focussing of this light
Our tears form a protective layer at the front of the eye and also help to direct the light coming into our eye. The iris, the coloured circle at the front of our eye, changes the size of the pupil which allows different amounts of light into our eye. The pupil is the dark hole in the middle of the coloured part of our eye. The pupil gets smaller in bright conditions to let less light in and gets bigger in dark conditions to let more light in.
The middle of our eye is filled with a jelly-like substance called the vitreous. The vitreous is clear and allows light to pass directly from the front to the back of our eye.
The retina at the back of the eye is a light-sensitive layer which consists of rod and cone cells. These cells collect the light signals directed onto them and send them as electrical signals to the optic nerve at the back of our eye.
Rod cells are concentrated around the edge of the retina. They help us to see things that aren't directly in front of us, giving us a rough idea of what is around us. They help us with our mobility and getting around by stopping us from bumping into things. They also enable us to see things in dim light and to see movement.
Cone cells are concentrated in the centre of our retina where the light is focused by the cornea and lens. This area is called the macula. Cone cells give us our detailed vision which we use when reading, watching TV, sewing and looking at people's faces. They are also responsible for most of our colour vision.
The optic nerve is made up of thousands of nerve fibres. These fibres pass the electrical signals along to our brain where they are processed into the image we are looking at.
Seeing can be likened to the process of taking pictures on a film with a camera which you then get developed. The retina is like a camera film which stores an image of what we are looking at. The image directed onto the retina is then sent along to the brain where it is processed, like developing a camera film. Therefore we actually 'see' in our brain with the light information sent to it from our eyes. This whole process happens very quickly so that everything we see is in focus.
About thyroid eye disease
Thyroid eye disease (thyroid orbitopathy or TO) is actually a condition of the soft tissues such as the fat and muscles surrounding the eyes. The condition is characterised by a period of inflammation and engorgement of these tissues, followed by a healing response.
The condition most commonly occurs in association with an overactive thyroid gland, but also occurs with an under active thyroid gland; an identical picture sometimes occurs when the thyroid gland is not itself affected.
Thyroid gland
The thyroid is one of the body's endocrine glands; these are glands which produce hormones. Hormones are chemical messengers in our blood streams, which co-ordinate long term changes in function. The thyroid is located in the neck just below the Adam's apple, and its hormones regulate our metabolism.
Diseases of thyroid
The main problem affecting the thyroid is auto-immune disease. Thyroid cancers also occur. The effect of thyroid disease is felt as either an over-activity or under-activity of the gland, and therefore either a speeding up or a slowing down of metabolism.
Auto-immune disease and the thyroid
Auto-immune problems are caused by inappropriate behaviour of the body's immune system. The immune system usually fights off infection but in auto-immune disease it attacks the body's own tissues with auto-antibodies. At the moment the reason for this is not entirely clear.
Why thyroid problems affect the eyes
When an auto-immune attack starts on the thyroid, it responds by producing more of its hormones. At the same time the auto-antibodies attacking the thyroid gland also attack the tissues around the eyes.
More information on thyroid problems is available from the British Thyroid Association, details at the end of this page.
How thyroid disease affects the eyes
The commonest problem is dry eyes. This is because, in auto-immune disease, more than one organ may be attacked, and commonly the thyroid and all the orbital contents (the soft tissues around the eye), including the lacrimal gland, are attacked by the immune system. The lacrimal gland produces the tears in our eyes, so when it is affected fewer tears are produced. As a result, the eyes may feel dry and gritty. It is worth noting that, although the eyes are described as 'dry', they can water and produce more tears than normal.
As the orbital contents (the soft tissues around the eye) become inflamed, all the tissues of the orbit become red and swollen.
The eyelids become puffy and red (lid swelling)
The muscles of the eyelids contract, producing a staring appearance (lid retraction)
• The muscles and fat surrounding the eye swells, pushing the eyes forward so that they bulge out of the orbits (exophthalmos)
Lid retraction and exophthalmos make the dry eye symptoms worse.
The swelling of the muscles which move the eyes produces unequal movements and double vision (diplopia)
The orbits may become painful, particularly on eye movement.
How thyroid orbitopathy affects sight
If the muscles become swollen, then this can affect how well the muscles are able to control the ability of the eyes to move together. This can cause double vision. This is a symptom which occurs when the eyes do not quite point in the same direction and therefore each sends a slightly different message to the brain. When this happens our brains 'see' two of everything. This can make activities like reading very difficult, and driving very dangerous. If someone develops double vision then they must stop driving, it is illegal to drive with double vision which isn't controlled.
If you do develop double vision then you have to inform the Driver and Vehicle Licensing Authority (DVLA) and, usually, they will contact your ophthalmologist for a medical report. If your double vision then becomes controlled with glasses at a later date the DVLA will declare you fit to drive. Not informing the DVLA of double vision could have serious consequences for your insurance status and you would be also be driving illegally.
In severe Thyroid Orbitopathy, especially in younger patients whose firm tissues do not allow the eyes to bulge forwards, the pressure inside the orbits increases, compressing the optic nerve and causing sight problems. The optic nerve carries the messages from the eye to the brain and can be damaged by pressure.
If the pressure starts to compress the optic nerve sight may become dim, colours begin to look washed out, and the visual field may constrict. If this starts to happen, then medical attention needs to be sought as soon as possible, to reduce the pressure on the optic nerve before permanent damage occurs.
The treatment options for optic nerve compression are steroids, immunosuppressant drugs, orbital radiotherapy and emergency orbital decompression surgery. These all aim to lower the pressure on the optic nerve and hopefully avoid permanent damage.
Treatment for thyroid disease
The first priority is to deal with the primary thyroid problem. This is firstly with anti-thyroid drugs, and then with either surgery or radiotherapy. The treatment of an overactive thyroid often produces an under active thyroid, which then requires treatment with thyroid replacement therapy. It is very important to be aware that the treatment of the underlying thyroid condition often makes the associated eye condition worse, and to be ready for this.
Thyroid orbitopathy treatment
When the eyes are dry and gritty then the best treatment is to use lubricating eye drops - artificial tears.
These can help to make the eyes feel more comfortable and help to prevent the eye being damaged by being so dry.
Treatment for double vision
A variety of treatments are available depending on whether the double vision is temporary or permanent. An orthoptist (an eye professional who specialises in double vision) should be involved in such treatments.
Occlusion
In this treatment, one eye is simply covered up so that the brain receives only one image.
Prisms
Prisms work by bending light in a direction which compensates for the angle between the eyes. They can be tailored to the angle between the eyes and affixed to spectacles. Stick-on prisms, often called Fresnel prisms, are used until it is established that the angle is constant, at which point prisms, can be incorporated into the spectacle lens by an optometrist.
In temporary double vision during the active stage of TO, prisms may be the only treatment necessary. As TO burns out, however, it often leaves some residual double vision requiring surgical treatment.
Long term ef
Skip to content
RNIB
Eye health
Recently diagnosed
Information for everyday living
Services we offer
Campaigning
Donations and Fundraising
Volunteering
RNIB helpline 0303 123 9999
About RNIB
Shop
Membership
FAQs
Research
Donate
Search
Back
Home
Eye health
Eye Conditions
Thyroid eye disease
Thyroid eye disease
Share this
Share on Facebook
Share on Twitter
Thyroid eye disease (thyroid orbitopathy or TO) is a condition of inflammation and engorgement of the soft tissues surrounding the eyes.
How the eye works
We need light to see what is around us and to see colour. Light bounces off the objects we look at. These reflect different amounts of light which we see as different colours.
Light rays enter the front of our eye through the clear cornea and lens. It is very important that both the cornea and lens are clear as this allows the light to pass directly through the front of the eye to the retina. The cornea and lens bends light so that it can focus on the retina at the back of our eye. This gives us a clear, precise image. The cornea focuses the light towards our retina. The lens fine tunes the focussing of this light
Our tears form a protective layer at the front of the eye and also help to direct the light coming into our eye. The iris, the coloured circle at the front of our eye, changes the size of the pupil which allows different amounts of light into our eye. The pupil is the dark hole in the middle of the coloured part of our eye. The pupil gets smaller in bright conditions to let less light in and gets bigger in dark conditions to let more light in.
The middle of our eye is filled with a jelly-like substance called the vitreous. The vitreous is clear and allows light to pass directly from the front to the back of our eye.
The retina at the back of the eye is a light-sensitive layer which consists of rod and cone cells. These cells collect the light signals directed onto them and send them as electrical signals to the optic nerve at the back of our eye.
Rod cells are concentrated around the edge of the retina. They help us to see things that aren't directly in front of us, giving us a rough idea of what is around us. They help us with our mobility and getting around by stopping us from bumping into things. They also enable us to see things in dim light and to see movement.
Cone cells are concentrated in the centre of our retina where the light is focused by the cornea and lens. This area is called the macula. Cone cells give us our detailed vision which we use when reading, watching TV, sewing and looking at people's faces. They are also responsible for most of our colour vision.
The optic nerve is made up of thousands of nerve fibres. These fibres pass the electrical signals along to our brain where they are processed into the image we are looking at.
Seeing can be likened to the process of taking pictures on a film with a camera which you then get developed. The retina is like a camera film which stores an image of what we are looking at. The image directed onto the retina is then sent along to the brain where it is processed, like developing a camera film. Therefore we actually 'see' in our brain with the light information sent to it from our eyes. This whole process happens very quickly so that everything we see is in focus.
About thyroid eye disease
Thyroid eye disease (thyroid orbitopathy or TO) is actually a condition of the soft tissues such as the fat and muscles surrounding the eyes. The condition is characterised by a period of inflammation and engorgement of these tissues, followed by a healing response.
The condition most commonly occurs in association with an overactive thyroid gland, but also occurs with an under active thyroid gland; an identical picture sometimes occurs when the thyroid gland is not itself affected.
Thyroid gland
The thyroid is one of the body's endocrine glands; these are glands which produce hormones. Hormones are chemical messengers in our blood streams, which co-ordinate long term changes in function. The thyroid is located in the neck just below the Adam's apple, and its hormones regulate our metabolism.
Diseases of thyroid
The main problem affecting the thyroid is auto-immune disease. Thyroid cancers also occur. The effect of thyroid disease is felt as either an over-activity or under-activity of the gland, and therefore either a speeding up or a slowing down of metabolism.
Auto-immune disease and the thyroid
Auto-immune problems are caused by inappropriate behaviour of the body's immune system. The immune system usually fights off infection but in auto-immune disease it attacks the body's own tissues with auto-antibodies. At the moment the reason for this is not entirely clear.
Why thyroid problems affect the eyes
When an auto-immune attack starts on the thyroid, it responds by producing more of its hormones. At the same time the auto-antibodies attacking the thyroid gland also attack the tissues around the eyes.
More information on thyroid problems is available from the British Thyroid Association, details at the end of this page.
How thyroid disease affects the eyes
The commonest problem is dry eyes. This is because, in auto-immune disease, more than one organ may be attacked, and commonly the thyroid and all the orbital contents (the soft tissues around the eye), including the lacrimal gland, are attacked by the immune system. The lacrimal gland produces the tears in our eyes, so when it is affected fewer tears are produced. As a result, the eyes may feel dry and gritty. It is worth noting that, although the eyes are described as 'dry', they can water and produce more tears than normal.
As the orbital contents (the soft tissues around the eye) become inflamed, all the tissues of the orbit become red and swollen.
The eyelids become puffy and red (lid swelling)
The muscles of the eyelids contract, producing a staring appearance (lid retraction)
• The muscles and fat surrounding the eye swells, pushing the eyes forward so that they bulge out of the orbits (exophthalmos)
Lid retraction and exophthalmos make the dry eye symptoms worse.
The swelling of the muscles which move the eyes produces unequal movements and double vision (diplopia)
The orbits may become painful, particularly on eye movement.
How thyroid orbitopathy affects sight
If the muscles become swollen, then this can affect how well the muscles are able to control the ability of the eyes to move together. This can cause double vision. This is a symptom which occurs when the eyes do not quite point in the same direction and therefore each sends a slightly different message to the brain. When this happens our brains 'see' two of everything. This can make activities like reading very difficult, and driving very dangerous. If someone develops double vision then they must stop driving, it is illegal to drive with double vision which isn't controlled.
If you do develop double vision then you have to inform the Driver and Vehicle Licensing Authority (DVLA) and, usually, they will contact your ophthalmologist for a medical report. If your double vision then becomes controlled with glasses at a later date the DVLA will declare you fit to drive. Not informing the DVLA of double vision could have serious consequences for your insurance status and you would be also be driving illegally.
In severe Thyroid Orbitopathy, especially in younger patients whose firm tissues do not allow the eyes to bulge forwards, the pressure inside the orbits increases, compressing the optic nerve and causing sight problems. The optic nerve carries the messages from the eye to the brain and can be damaged by pressure.
If the pressure starts to compress the optic nerve sight may become dim, colours begin to look washed out, and the visual field may constrict. If this starts to happen, then medical attention needs to be sought as soon as possible, to reduce the pressure on the optic nerve before permanent damage occurs.
The treatment options for optic nerve compression are steroids, immunosuppressant drugs, orbital radiotherapy and emergency orbital decompression surgery. These all aim to lower the pressure on the optic nerve and hopefully avoid permanent damage.
Treatment for thyroid disease
The first priority is to deal with the primary thyroid problem. This is firstly with anti-thyroid drugs, and then with either surgery or radiotherapy. The treatment of an overactive thyroid often produces an under active thyroid, which then requires treatment with thyroid replacement therapy. It is very important to be aware that the treatment of the underlying thyroid condition often makes the associated eye condition worse, and to be ready for this.
Thyroid orbitopathy treatment
When the eyes are dry and gritty then the best treatment is to use lubricating eye drops - artificial tears.
These can help to make the eyes feel more comfortable and help to prevent the eye being damaged by being so dry.
Treatment for double vision
A variety of treatments are available depending on whether the double vision is temporary or permanent. An orthoptist (an eye professional who specialises in double vision) should be involved in such treatments.
Occlusion
In this treatment, one eye is simply covered up so that the brain receives only one image.
Prisms
Prisms work by bending light in a direction which compensates for the angle between the eyes. They can be tailored to the angle between the eyes and affixed to spectacles. Stick-on prisms, often called Fresnel prisms, are used until it is established that the angle is constant, at which point prisms, can be incorporated into the spectacle lens by an optometrist.
In temporary double vision during the active stage of TO, prisms may be the only treatment necessary. As TO burns out, however, it often leaves some residual double vision requiring surgical treatment.
Long term ef
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