Bulgy eye surgery CENTER FOR FACIAL PLASTIC SURGERY AT ENT SPECIALISTS

Bulgy eye surgery

Thyroid eye disease (TED), also known as Graves disease, can lead to bulging eyes, double vision and sometimes loss of vision. Once the disease becomes stable, surgery can be done to improve the function and the aspect of the eyes.

Hyperthyroidism (high thyroid hormones) is not the actual cause of thyroid eye disease. It is an autoimmune disease, typically Graves or Hashimotto, that can affect both the eyes and the thyroid gland and lead to Thyroid Eye Disease (TED). Patients should stop smoking as soon as they are diagnosed with TED, otherwise they have a 20 times higher chance of severe complications, such as permanent vision loss.

Most patients start experiencing eye problems as soon as their thyroid gland becomes overactive. For some, the eye changes may develop before hyperthyroidism is detected. Others may not develop symptoms until months or years later. Both eyes are usually affected, but not necessarily to the same degree.

In mild cases, the common symptoms are: pressure around the eyes, ocular irritation and tearing. In severe cases, the inflammation of the eye muscles may result in restricted eye movement causing double vision. If the muscles become too swollen, they can sometimes compress the optic nerve resulting in progressive loss of vision.

The disease usually becomes inactive after 6 months to 2 years. At that time the patient is left with bulgy, dry eyes, double vision and retracted eyelids.

TREATMENT
In the acute, inflammatory phase, intravenous infusions of Teprotumumab (TEPEZZA) or steroids (Methylprednisolone) can decrease the swelling and the risk of developing further, permanent changes around the eyes. Both drugs can however have severe side effects and should be administered only when benefits heavily outweigh the risks. In a minority of cases (5-8%) the inflammation is severe enough to produce vision loss from compression on the optic nerve. If there is no improvement after 2 weeks of intravenous steroid treatment, orbital decompression surgery is necessary to save the patient’s vision.

In the inactive or stable phase of TED and only in patients who haven’t smoked in 6 months, surgery can be performed to correct the protruding eyes and the retracted, eyelids. Blepharoplasty with fat sculpting or transposition for cosmetic reasons is typically the last procedure performed, after orbital decompression and strabismus surgery. Brow fat pad sculpting is usually necessary and performed at the same time.

Orbital decompression.
Lateral orbital wall decompression surgery is the procedure of choice in those patients that do not have double vision. It is the only technique that can reposition the eyes with

minimal risk (less than 1%) of new onset or worsening double vision. The procedure is performed through an upper eyelid skin crease incision and involves removing the back part of the bony lateral wall of the eye socket allowing the eyeball to move backwards. The same incision is usually used to remove the excess fat around the eyes and to correct the eyelid retraction. In most cases this procedure is sufficient to regain the normal eye appearance.

When the eyeball needs to be retro-placed (set back) more than 4 mm in order to achieve the desired functional and cosmetic result, a Balanced Decompression is performed. This procedure has a risk (10-20%) of postoperative double vision but can allow the eye to move back up to 6-8 mm. During this procedure, the lateral and the medial walls are removed together with the swollen fat from behind the eye. In the small minority of cases where double vision does appear or worsens after the procedure, a second surgery to realign the eyes, called strabismus surgery, is performed 4-6 months later.

Surgery is performed under general anesthesia and takes about an hour. The patient returns home one hour after the surgery. Typically, one eye is operated at a time although, in selected cases, both eye sockets can be decompressed at the same setting.

Eyelid retraction surgery. Both upper and lower eyelid retraction commonly occur in patients suffering from Thyroid Eye Disease (TED). Fortunately, eyelid retraction is correctable and typically done at the same time as the orbital decompression surgery.

Upper eyelid retraction correction called Müllerectomy is performed through the inside of the upper eyelid. Lower eyelid retraction correction is performed through the same incision used for the orbital decompression surgery and involves releasing the lower eyelid retractors, horizontally tightening and vertically lifting the lower eyelid. The horizontal tightening of the eyelid is achieved through a procedure called canthopexy or canthoplasty that tightens the lateral eyelid tendon. The vertical lift of the lower eyelid is achieved using a mid-face lift technique that provides support to the lower eyelids and pushes it upwards. When the eyelid retractors are released, a spacer is sometimes inserted inside to vertically elongate the eyelid.

Blepharoplasty. Often, a Blepharoplasty is performed 4 to 6 months later to improve the cosmetic result. However, the blepharoplasty should be done only after the decompression and the strabismus (eye alignment) surgery have been performed (if necessary). Sometimes, the eyelid retraction surgery and the blepharoplasty are done together as a final cosmetic and reconstructive procedure. In selected cases, the blepharoplasty can be done at the same time as the orbital decompression surgery.