Surgery is generally reserved for quiescent (inactive) disease, once inflammation has settled. The exception is urgent orbital decompression for loss of vision caused by compression of the optic nerve (optic neuropathy).
Thankfully, modern medical therapy has made emergency decompression rare. If orbital decompression is needed, it is performed first to bring the eye back into the socket.
There’s a small (<10 percent) risk of reactivating the active phase of the disease after surgery, though this is rare.
The surgical options consist of the following:
• Orbital decompression. Orbital decompression involves expanding the bony walls of the eye socket (orbital cavity) and is often combined with removal of some orbital fat. Orbital decompression surgery is the mainstay of rehabilitation for TED; it can improve nearly every aspect of the disease, from vision-threatening optic nerve damage or corneal exposure to cosmesis. Quality of life is often better after surgery, since orbital congestion, pain and dry eye can improve. Common complications include double vision and scarring (5 to 25 percent, depending on the technique used), while rare complications include vision loss (<0.5 percent, partial or total in the operated eye).
Surgery is performed under general anaesthesia through skin incisions hidden in the natural folds of the eyelids, takes around 90 minutes and is usually done as an inpatient.
• Strabismus surgery. Double vision that persists may be either controlled with prisms or require eye muscle surgery (strabismus surgery) in order to align both eyes better. Surgery to adjust the extraocular muscles and improve double vision is commonly performed. However, this can be much more complicated than typical strabismus surgery, and needs to be performed by a surgeon who is experienced in thyroid eye disease. This surgery takes between 30 to 60 minutes and can be performed under general anaesthetic or local with sedation. Patients can have significant improvement if the muscles aren’t too scarred.
• Eyelid surgery. Surgery to improve eyelid retraction (‘stary look’) is often the final step in rehabilitation. This step can also be the most temperamental, as the eyelid structures are incredibly minute and unpredictable. However, significant improvement can be achieved. Surgery is performed under local anaesthetic with or without sedation and can take between 30 to 60 minutes.
• Cosmetic surgery. While thyroid eye disease primarily affects the tissues inside the orbit, there are significant changes in the skin and fat in the eyebrows, cheeks, neck and other areas of the face. These various changes can be addressed with a combination of fillers, botulinum toxin (i.e., Botox), or even surgery for the eyelid, eyebrow, face and neck. Great care must be taken when undergoing cosmetic surgery in the context of thyroid eye disease: Treating a TED patient like any other cosmetic surgery patient can, at best, lead to a hollow, unnatural look and, at worst, lead to severe corneal exposure and loss of vision or even loss of the eye.
