Graves disease, also known as thyroid eye disease or thyroid associated ophthalmopathy, is a disorder that can affect the eyelids, eye muscles, and orbit. Findings include exophthalmos (proptosis), or a bulging eye, eyelid retraction, dry eyes, eyelid and eyebrow swelling, and double vision.
There are several treatments available, and management depends on signs and symptoms.
Management is typically done in 3 stages. One or more surgeries may be performed within each stage.
Stage 1: Orbital decompression
Stage 2: Eye muscle surgery
Stage 3: Eyelid surgery
Orbital decompression surgery:
This is a procedure that relieves the pressure in the orbit by expanding the orbit. The orbit, or eye socket, is surrounded by the sinuses. Dr. Isaacs specializes in minimally invasive orbital decompression surgery. Small hidden incisions in the upper eyelid crease, on the inside of the lower eyelid (transconjunctival), and through the inner corner of the eye (trans-caruncular) can be used to access the orbit. Bone can then be precisely shaved or removed in order to provide expansion. The sinuses can be visualized and air cells can be opened and removed as well. Finally, orbital fat may be removed to further add more room in the orbit for the eye.
Dr. Isaacs’ thesis paper was both an original investigation and a thesis on anatomy and physiology, titled “Pneumatization of the Palatine Bone, Nasal Turbinates, and Sinuses: Anatomic Relationships and Considerations for the Orbital Surgeon.” His work included radiographic and cadaveric studies to determine anatomic relationships and how they can be optimally used during surgery. Furthermore, his work highlights an anatomic structure that can be accessed during surgery to help with orbital decompression, especially in patients with optic neuropathy and at risk for blindness.
A detailed anatomic knowledge of the bony orbit, eye, and contents within the orbit, is crucial to orbital surgery. In fact, in the early period of Dr. Isaacs’ fellowship training, one of his mentors advised him that an orbital surgeon should know the anatomy so well that he/she should be able to operate in the dark or with the eyes closed. Well, this actually occurred to Dr. Isaacs! He was operating in a child’s orbit with a malignant tumor when the entire power went out at a major academic institution! Rest assured, the child did extremely well without any complications.
Eye muscle surgery:
This is a procedure for patients who have double vision in primary gaze, or when they are looking straight ahead. The procedure attempts to give patients a single tunnel of vision when looking straight ahead.
There are various types of eyelid surgery performed for Graves’ patients, and they can be performed on the upper and/or lower eyelids. Typically, the goal of eyelid surgery is to lower the upper eyelid and raise the lower eyelid in order to better protect the eye from the elements and decrease the exposure.