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Dr-Trace
Dr-Trace, Board Certified Ophthalmologist
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Experience:  Board Certified in General Ophthalmology
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At what point would you make the recommendation that thyroid

Resolved Question:

At what point would you make the recommendation that thyroid surgery be a better option for treatment of the Graves disease than I131 treatment? The endocrinologist is awaiting the recommendation of the neuro-ophthalmologist regarding Graves treatment. IV prednisone has made some improvement of the eye swelling and ocular movements. But mild symptoms return as it gets 5-6 days post IV steroid therapy. Today he received IV #3.
Submitted: 2 years ago.
Category: Eye
Expert:  Dr-Trace replied 2 years ago.

Dr-Trace :

Hi I am Dr. Lewis and I would like to share a little information from an ophthalmologist's point of view regarding your question. The problem with eye swelling in Grave's disease is not caused by the thyroid. It is caused by antibodies produced by the immune system that attack the thyroid and also cross react and attack the muscles of the eye in the orbit. So it is difficult to answer your question regarding which procedure would be better for the thyroid. If there is less thyroid to attack by the antibodies, there will be less antibodies (possibly) but usually the muscle swelling in the orbit does not go down. Studies have shown that the extraocular muscles swell because of deposition of GAG proteins into the muscles (as a response to being attacked by antibodies) and this may be why your husband's symptoms are not getting better with steroids. If there is acute swelling in the muscles from attack by antibodies, this can be suppressed by IV steroids. But any GAG protein deposition in the muscles has already occurred and will not be helped by steroids.

Dr-Trace :

Surgical treatment or radiation treatment of the muscles of the orbit can debulk the swelling and this may be the option of choice for your husband. Ask the neuro-ophthalmologist.

Dr-Trace :

Hope this helps.

Dr-Trace :

Dr. T

Dr-Trace :

Hi - I am Dr. T and I am ready to answer any further questions you have.

Customer:

I understood that treatment with I131 could worsen the ocular effects from the already present thyroid antibodies. Did I misunderstand?

Dr-Trace :

No I don't think you misunderstood. I believe that destruction of the thyroid with I131 still leaves tissue that is susceptible to thyroid antibodies even though it is not viable thyroid tissue. The markers for the antibodies are still on the tissue. Therefore this would make sense since the antibodies would still circulate and attack the extraocular muscles.

Dr-Trace :

Removal surgically of thyroid tissue would remove the stimulus for the antibodies to attack and the attacks on the eye muscles would then also lessen.

Customer:

Can the thyroid antibodies continue to cause worsening of the TED even after treatment?

Dr-Trace :

The goal is to lessen the circulating antibodies as much as possible. So after surgical removal of lobes of the thyroid, there should be less circulating antibodies. But remember these same antibodies are still stimulated by the extraocular muscles themselves(cross reactivity) so they can still attack to a certain degree the extraocular muscles.

Customer:

Essentially we can treat the Graves and still potentially have continual, possibly worsening, TED? Any last suggestions?

Dr-Trace :

Yes. The thyroid eye disease treatment should be geared to realigning the muscles to minimize the diplopia (strabismus surgery) as well as treatments designed to debulk the swelling of the extraocular muscles. Radiation to the muscles is an option and I believe there are some other promising treatments but I am not an expert in the most current orbital treatments of thyroid eye disease. Again though, I think the focus should be on correcting the extraocular muscle problems.

Customer:

Thank you.

Dr-Trace, Board Certified Ophthalmologist
Category: Eye
Satisfied Customers: 26
Experience: Board Certified in General Ophthalmology
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