Graves Orbitopathy

Thyroid Eye Disease (TED) or Graves Orbitopathy (GO) is a condition that affects about 400,000 people in the UK and is often, but not always, associated with an overactive thyroid gland (Graves Disease). The eye muscles, eyelids, tear glands and fatty tissues behind the eye become inflamed and the eyes can be pushed forward (‘staring’ or ‘bulging’ eyes). This can have profound physical and psychological consequences

 About the Service

Here at Imperial College Healthcare Healthcare NHS Trust, we run a comprehensive thyroid eye disease service with enormous experience in the management of all presentations of this complex disease, led by Vickie Lee and her ophthalmology colleagues, Ahmad Aziz, Rashmi Akshikar and Rajni Jain. The Endocrinologists include Karim Meeran, Vasiliki Bravis, Claire Feeney, Parizad Avari and Kleopatra Alediadou.

Evaluation of a patient with Graves Orbitopathy is performed by an endocrinologist, a doctor who specialises in hormones together with  eye doctors (ophthalmologists) and technicians (orthoptists) in one of our  multi-disciplinary (MDT) clinics . We assess each patient’s symptoms with a  careful clinical examination including  quantitative measurements of the eye movements.

The best type of scan to study TED   is called a Magnetic Resonance Imaging (MRI) scan. This involves lying still on a bed in a long tube for up to an hour. We have developed dedicated MRI imaging for our TED patients to measure the level of inflammation in the muscles of that move the eye and these measurements help guide our treatment.

If the MRI scan suggests that the TED may be causing significant inflammation, together with the Clinical Examination and  Orthoptic (eye movement) measurements then anti-inflammatory (immunosuppression) treatment  in the form of intravenous steroids may be recommended, in our Day Unit. This is done in conjunction with careful control of the patient’s thyroid hormone levels.

What happens if I have Thyroid Eye Disease?

TED patients are seen at one of our monthly thyroid multidisciplinary clinics. This ensures that all the main healthcare professionals (endocrinologists and  ophthalmologists)  involved in the care of these patients discuss the best way to manage their TED  and a clear treatment plan is made for each patient. We will constantly evaluate how the patient’s quality of life is being affected with regular measurements of Quality of Life. We have a network of specialists based in the Trust to ensure seamless care. (see diagram)

Treatment options depend on the severity and activity of TED .

It is also extremely important to stop smoking and to ensure the thyroid hormone levels are controlled with medication and sometimes surgery or radio-iodine treatment.

Mild TED usually do not need any treatment apart from thyroid control, Selenium supplements and tear supplements for irritable eye symptoms.

About 1 in 3 patients develop significant swelling and stiffness of the muscles that move the eyes so that these muscles no longer move in line with each other leading to double vision. In about 1 in 20-30 patients TED can cause reduced vision from pressure on the nerve at the back of the eye or ulcers forming on the front of the eyes if the eyelids cannot close completely. Patients with moderate, severe and sight threatening disease need specific treatment for their eye disease usually with steroids infusions sometimes you may be offered additional treatment, including surgery, medication and radiotherapy (high energy x rays). 

When TED and the thyroid hormone control has stabilised, if the patient is still left with significant disfigurement or double vision then rehabilitation surgery such as orbital decompression to reduce the bulging eyes, eye muscle surgery to correct double vision and eyelid surgery may be recommended.

How will I be monitored?

Your follow up care depends on the severity and activity of the TE , but generally will involve clinical review in MDT Thyroid Eye  clinic, further blood tests, MRI scans.