Graves’ Disease Eye Surgery

Endoscopic orbital decompression is a surgery to treat Graves’ orbitopathy (thyroid eye disease). It removes the middle and bottom walls of the bone surrounding the eye. Surgeons use endoscopes and small instruments working through the nose.

Removing these walls allows us to expand the swollen tissues in the eye into the sinuses. This reduces the bulging appearance of your eyes.

Sometimes, depending on the extent of the disease, the surgeon will need to decompress the outside wall of your eye as well. This is done through a small incision on the side of the eye toward your forehead. 

At the University of Utah, endoscopic orbital decompression surgery is done with a team of surgeons trained in both orbital and sinus surgery.

Treating Graves’ eye disease is done through a coordinated multi-specialty practice between endocrinologists, ophthalmologists (eye doctors), and rhinologists (endoscopic sinus surgeons). It is important to be seen and evaluated if you have Graves’ orbitopathy because, in rare cases, it can affect your vision.

thyroid eye disease diagram

Benefits and Risks of Endoscopic Orbital Decompression

By removing part of the walls of the eye bones (or orbit), endoscopic orbital decompression may allow the eye to move back into a better position in the eye socket. This may:

  • Reduce eye dryness
  • Reduce tearing
  • Reduce abrasions of your eye
  • Affect even the appearance of your eye

Endoscopic orbital decompression may also decrease the pressure inside your eye socket. This can prevent or improve double vision or loss of vision.  

While it’s difficult to estimate success rates because each patient is very different, this procedure is worth discussing with your surgeon.

Endoscopic orbital decompression involves operating both in the eye and in the sinuses. Risks include but are not limited to the following:

  • Loss of vision
  • Double vision
  • Inadequate decompression of the eye
  • Bleeding around the eye
  • Cheek numbness (from damage to the cheek nerve)
  • Nosebleeds
  • Leakage of brain fluid (cerebrospinal fluid/CSF)
  • Meningitis
  • Infection of the eye
  • Injury of the tear duct (which can cause excess tearing)
  • Sinusitis

What to Expect at Endoscopic Orbital Decompression Surgery

Healing

The majority of the healing in your nose will take place over the next four weeks. In some patients, the process can take longer. 

Medications

You should have received prescriptions for medications to take after surgery. Typically, these include pain medicine and possibly antibiotics. These medications are essential components of your care, promoting rapid and correct healing.

Bleeding

Oozing from the nose is common for 24-48 hours following surgery.

Nausea

Nausea and even vomiting following anesthesia are common. The nausea usually fades after about 12-24 hours. You can try to sip liquids to avoid dehydration during these periods.

Pain

Some discomfort following the procedure is to be expected but usually is not especially severe.

Irrigating

This is one of your most important jobs after surgery. The crusting of blood and mucus can slow the healing process. To keep your nose moist and prevent crusting, you should use saline (salt-water) nasal irrigation following surgery. A simple system to use is NeilMed’s Sinus Rinse, available at many pharmacies.   

Fatigue

Fatigue for two or three days following the surgery is common. You will want to take it easy for a few days following surgery. You should also avoid strenuous physical activity. Moderate activity (like going for a walk) is acceptable.   

Work

Most individuals return to work within a week following surgery. Some return earlier, some later. Plan to be out for a week and return as soon as you feel up to it.

Travel

Many of our patients travel from some distance. If possible, it is helpful to stay in the local area overnight following the surgery. If necessary, you may travel by air 48 hours after the surgery.

Post-Operative Visits

The care of your sinuses and orbit surgery does not end when the surgery is completed. Post-operative visits are critical. During these visits, your physician will examine your nose. Removal of dried blood and mucus may be necessary while the nose regains its ability to care for itself. 

Frequently Asked Questions about Graves' Disease Eye Surgery

My doctors tell me they fixed my thyroid and that it is now normal. Why are my eyes acting up?

In Graves' disease, the immune system stimulates the thyroid gland to secrete too much hormone. This excess hormone results in nervousness, palpitations, weight loss, diarrhea, tremors, and a feeling of being hot all the time. Treatment is aimed at limiting the thyroid gland's ability to make thyroid hormone. This may be done with medications, surgery, or radioactive iodine, usually resulting in thyroid hormone production normalization (occasionally requiring thyroid replacement). However, this does not affect the primary auto-immune process, and the immune system may continue to target other tissues, particularly the extraocular muscles in the eye and eyelid. Orbital symptoms may even worsen following treatment with radioactive iodine. The eye and orbit changes are treated separately.

The steroids made my eyes much more comfortable. Can't I just continue taking them?

Steroid therapy can effectively halt the inflammatory phase of thyroid orbitopathy while also partially reducing muscle swelling. But taking too many steroids can have off-target side effects, so we limit their use as much as possible. If there are still problems with eye movements (double vision), exposure problems (irritation and foreign body sensation), or decreased vision, surgery should be considered.

Why can't you fix my eyelids now?

Surgery on the muscles that move the eye up and down may change the eyelid position. Thus, we wait to do eyelid surgery until we have addressed any possible changes from muscle surgery.

Can't you just put my bulging eyes back in place?

We can reduce the bulging of your eyes by doing endoscopic orbital decompressive surgery. If you already have tight muscles, decompressing the orbit may produce double vision. This is usually treatable with eye muscle surgery. Still, if you don't have double vision and your central vision is normal, we may be able to deal with the bulged appearance with lid surgery alone, without the risk of double vision.

Why do you want to operate on my "good" eye?

Eye muscle surgery may release a restricted muscle, but the muscle is often incapable of moving normally due to its enlargement and fibrosis. In other words, if we operate only on the more affected eye, that eye will have very limited movement and you will have double vision whenever you look to the side. By limiting the movement of the other eye, we can maximize the area over which you can see.

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