How Long Thyroid Eye Disease/Graves Disease Lasts, and Reducing Eye Prominence

Thank you
for your question. You submitted your question with two photos. And you describe in your question that you
had issues with discomfort in one eye. And that in 2014, you were diagnosed with
thyroid eye disease and you underwent a fat removal or orbital decompression surgery by
an oculoplastic surgeon at that time. You still felt concern about the appearance
of your eyes and so you underwent eyelid surgery in 2016. Now currently, you state from your question
that you hate the appearance of your eyes and you’re considering another decompression
surgery and you’re looking for additional opinions based on the photos that you submitted. Well, I can certainly share with you my approach
to dealing with patients with thyroid eye disease. A little bit of background, I’m a Board-certified
cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long
Island for over 20 years. Thyroid eye disease has been a very big part
of my practice. And I perform the full gamut of procedures,
everything from orbital decompression to eyelid surgery. And I can certainly understand your challenges
that you’re dealing with in terms of your desire to improve you appearance. So to begin with, I think that one thing to
be sure of is that if you’ve been going to an oculoplastic surgeon who has been doing
this work in a stepwise way, I think that your doctor will be the best person to guide
you as to what the next steps are. And I’ll explain a little bit further. When we talk about the concept of what happens
with thyroid eye disease and understanding that there are two phases: there’s the active
inflammatory phase and there’s the fibrotic phase. And generally speaking, you try to avoid operating
during the inflammatory phase unless there is a very clear indication such as visual
threatening disease that requires surgical intervention at that time. Typically, the active inflammatory stage where
there’s this autoimmune process and variability of the eye appearance, you can expect that
it can last about 2 years. In the medical literature, it can last up
to 5 years but that’s really the rare instances. Basically determining where someone’s in
the fibrotic stage is contingent mostly on the clinical appearance based on the stability
of the eye appearance. And of course, from that point, you do surgeries
to help people improve their eye function and eye appearance. So with the fat decompression, it was likely
done because you had an issue with the proptosis or the prominence of the eye being pushed
forward. And that approach can be very effective in
reducing the volume that is behind the eyes since in thyroid eye disease, there is an
increase in certain types of thyroid eye disease proportionally in the amount of fat behind
the eye. Now the question at this point is what do
you want to see change? If you want to see projection of the eye change,
well it’s important you discuss with your doctor what are your other options. It is likely your doctor probably did as much
fat decompression as is safely possible from your initial surgery which leaves you with
a procedure called bony orbital decompression. And in bony orbital decompression, you’re
actually removing parts of the bone in the orbit such as the bones of the ethmoid sinus
above the maxillary sinus. And even further, you can actually reduce
the bone in the lateral aspect in the lateral part of the orbit or the greater wing of the
sphenoid. This is more of a technical jargon but it
basically means that you are doing a more aggressive operation and with that comes certain
risks that you need to be aware of. Now if you are more concerned about the appearance
of the eyes in terms of the retraction, well I think that it is likely you can do additional
eyelid surgery which can address the eyelid retraction. This includes surgery to address lower eyelid
retraction as well as upper eyelid retraction. Now you mention that you did have this surgery
or eyelid surgery and you weren’t exactly specific. But nonetheless, as long as you have an understanding
as to the risks and benefits, I would probably say, coming from a conservative perspective
that, again, without a physical examination but at least understanding how I counsel my
patients, I ask them how much does the prominence of the eyes bother you. And very often, if I show them that the eyelid
being brought down, let’s say in the case of the upper eyelid and brought down a little
bit, it’s remarkable how it can really change the perception of prominence. Basically, if the eyelids are retracted, the
eyeball looks more prominent. And so, it’s basically both an optical illusion
but at the same time, it is also functionally more comfortable for the patient to be able
to close their eyes. You know, with fat decompression, I’ve observed
that even if you don’t get that much of a retrusion of the eyeball, the eyeball does
move a little bit more easily and the blinking actually becomes more comfortable. Again, this is clinical experience. But I think that when I present to a lot of
my patients what their options are, they tend to shy away from bony orbital decompression
because of the extent of the procedure. It’s not saying that it’s not a good procedure. It’s actually a very effective procedure
but I think it’s best reserved for more severe cases of proptosis. So that being said, I think it’s very important
that you speak to your oculoplastic surgeon about your situation. What differentiates your doctor’s perspective
from someone else is their familiarity with your anatomy. Now certainly, as a specialist, as someone
who sees patients and takes care of patients from around the world, I have been in a position
to do revision eyelid surgery whether it’s for eyelid retraction or eyelid ptosis and
other eyelid situations. Certainly, it’s okay to have other opinions
and have at least an understanding but I think that you should have this discussion first
with the surgeon who has done the surgery for you already. Now if they feel that they’ve done as much
as they could and they don’t want to do anything more, then seek additional opinions. But at the meantime, I think that it is important
for you to understand and have this discussion about bony decompression versus additional
eyelid surgery. And although there’s no examination here,
I suspect, based on your photos, that you might find a middle ground of compromise with
the eyelid surgery over the decompression. I think that one of the things that I have
counseled on my patients who have thyroid eye disease which very often affects young
to middle aged women and the significant impact of this disease on their physical appearance
can be quite devastating and very emotionally impactful. And so understanding that it is accepting
a change that is very difficult to restore to the pre-thyroid disease appearance but
nonetheless, having a natural aesthetic appearance is possible and that, I think, is important
to at least just get comfortable with. It’s never ideal but it is, unfortunately,
just the physical realities of these long-term anatomic changes from this autoimmune disease. So I hope that was helpful, I wish you the
best of luck and thank you for your question.


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