Common eyelid problems that can relate to dry eye disease, Part 2: Say Hi to “TED.”

TED is not this patient’s real name but the acronym as described below. The rights to this photo belong to the company making the treatments described below and in this link: Tepezza

Exposure from eyelid retraction– “The Thyroid Stare” (Exposure from: Thyroid Eye Disease=TED, related to the higher levels of thyroid hormone) and/or proptosis from thyroid-related inflammation (among other inflammatory causes) behind the eye, causing eyeball “bulging.” Some unfortunate patients may have a combination, causing a high degree of eye exposure (as in the top photo before treatment, above - vs the lower above photo, after treatment) – resulting in dry eyes even when tears are otherwise good (but especially bad if the tears are “bad”). Untreated, in some cases this can lead to permanent loss of vision.

Conditions where inflammation gets behind the eye can cause the eye to be “pushed forward” - a condition called proptosis or exophthalmos, it results in the eye bulging out of the natural protection of the “bony cave” of the skull (the “orbit”) – to where the surface is exposed more than normal. This is common in Thyroid-related eye disease (TED), but can be found in other cases of genetically “shallow” orbits, inflammation, infection or from tumorous growths behind the eye(s).

If someone has TED (or any other reason for an over-exposed eyeball), then there are standard, and then newer treatments available, depending upon the degree of involvement and how much damage exists - or is at risk to exist. Job number one is to make great tears – since great tears can take good care of even very exposed eyes and bad tears can be especially bad for these eyes.

The clinical goal is to keep eyes safe and comfortable – but this can sometimes sacrifice form over function. By this, I mean that surgeries can be done to pull lids partially together (a so-called lateral and sometimes medial tarsorrhaphy) or to put a spacer into the lid to let it drop down to cover the eye better, but this may not look as cosmetically pleasing as if the eye were just to “look normal.”

This image is an example of a lateral tarsorrhaphy taken from the archives of the American Academy of Ophthalmology AAO photo and shows how the lids are brought closer together to partially cover an otherwise overly exposed eye. The cloudy, raised spot over the pupil is a corneal scar caused by excess exposure and can reduce vision in ways that is difficult to repair.

“Standard” therapy begins with all the “usual” homework for dry eye (see my earlier posts on this) and efforts to produce more and better tears as eyes bulge and exposure worsens. Adding lubricants, Autologous Serum Tears, sleep goggles and ointments at nighttime, and anti-evaporative wraparound glasses by day - can be increasingly helpful, as is true for most advanced dry eye patients. Monitoring how the inflammation and congestion behind the eye is affecting the eye-movement muscles, and the nerves involved with sensation - and particularly with vision – is key to maintaining eye health. If the eye’s health becomes compromised (double vision, pressure on the nerves, over-exposure of the eyes), then increasing levels of intervention are often required.

The common advanced interventions included steroids (prednisone) to reduce inflammation, radiation (when steroids prove insufficient or poorly tolerated) and surgeries (to decompress the swelling behind the eyes) – where bone and inflammatory tissues are removed to “make room” behind the eyes - as required to preserve eye health and function. Inflamed muscles will swell and cause poor function, resulting in double vision. Too much swelling can “pinch” the nerves, causing pain and permanent loss of vision, or cause over-exposure, causing damage to the surface of the eyes. Eventually the inflammation tends to “burn out” – so conventional wisdom was to address swelling with enough treatments to buy enough time for the inflammation to eventually subside. Smoking tobacco is like adding gas to the fire of inflammation and is strongly discouraged.

Fortunately, Tepezza is a new medication used as an infusion to fight the source of the inflammation unique to TED and has proven extremely effective against the swelling and related damage. Like most strong medications used to treat bad diseases, it can have a host of side effects that need to be weighed against the risks of the disease it is treating. These are generally manageable, but can include permanent, irreversible hearing loss in some, so proper monitoring of progress is equally important and choosing this treatment is best left to experts in the field. Dry eye doctors can help support the health of the surface of the eyes by promoting great tears and assisting in the monitoring of surface health if the disease progresses.

To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:

155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020

3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463

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Common Eyelid problems related to dry eye disease, Part 3: The eyelid “outtie.”

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Common eyelid problems that can relate to dry eye disease, Part 1: Bad lashes.