Thyroid Eye Disease (TED), for patients
David Kinshuck

• Information for patients
  links &
  Thyroid Eye Disease Charitable Trust (TED)
• smoking
• TSH receptors
• Radioactive iodine and autoimmune disease
• thyroid antibodies
• Features of thyroid eye disease
• thyroid and eye activity

• Thyroid Eye Disease Charitable Trust
  • PO Box 1928, Bristol, lBS37 0AXR, England
  • tel: 0844 8008 113        [email protected]   www.tedct.co.uk
• RNIB link  help leaflet etc
• leaflet    another
• Thyroid eye disease is described on the sites above. However, there has been tremendous progress in understanding the condition which is very important and not emphasised.
  Thyroid Eye Disease is often called Graves disease...basically these terms have the same meaning..

TED (thyroid eye disease) is up to 7 times worse in smokers  (Bartalena 98), Premmel 1993. That is SEVEN times worse. So do try to stop! The figure relates to approximately 20 cigarettes a day.
Passive smoking, that is if your husband smokes 20 cigarettes a day, means that you will get 25% of his smoke....so this if he smokes 20/day and you are in the same room much of the time, your eye disease will be THREE times as severe as if he did not smoke.

Smoking increases TSH receptors on the cells in the orbit (these are TSH receptors are described in the paragraph below.

The eye disease is due to abnormal TSH receptors on the surface of the cells surrounding your eyes. Why does this matter?
TSH is thyroid stimulating hormone, and is made in your pituitary gland. The pituitary gland makes more TSH when the amount of thyroid hormone in your blood drops to very low levels. If anyone is short of thyroid hormone, that is if you have had radiation treatment or a high dose of anti-thyroid drugs, or you become short of it naturally, the pituitary gland makes more TSH.

But the more TSH there is, the more that will reach the tissues around your eye, and then the more the muscles and fat around your eye will swell up, pushing your eye forward. This is because the TSH makes the cells swell up. (That is if you have thyroid eye disease with thyroid antibodies in the blood. If you do not have thyroid eye disease and have no thyroid antibodies the high TSH will not affect the eyes, although it will affect other parts of the body.)

You therefore need a low TSH level, or at least one that healthy people have. Therefore you will need blood checks to see that you have enough thyroid hormone in your bloodstream. By keeping the right amount of thyroid hormone in your blood your eyes are much less likely to swell up.
If your thyroid hormone levels are low your doctor will prescribe more thyroxine tablets.

Smoking increases TSH receptors, and can therefore make the condition much worse.

• Radioactive iodine may cause thyroid eye disease progression .
• Risks may be reduced by corticosteroid therapy starting just before the radioactive iodine.
• Radioactive iodine is best avoided with newly diagnosed disease (Graves disease) and active eye disease (Drug & Ther Bulletin 2006).
  
  

TSH receptor antibodies (TRAab) play a critical role in this disease. These are present in the disease, and essentially if the blood level rises the disease becomes more active, and if the levels drop, less active.

TED is therefore an 'autoimmune' disease. Autoimmune diseases are diseases when the body produces antibodies or cells that 'attack'  or target parts of the body, causing damage and problems. As with other autoimmune diseases, only part of the condition is understood. Smoking increases the autoimmune activity, and steroids and other anti-inflammatory treatment reduces it.

Unlike other auto-immune disease, TED is only usually active for 2 of years, and will become less active naturally. But the TED may become a severe problem during this in some people, and so during the 2 year period intensive treatment will be need in some people.

However, in most people the condition is not very serious, and steroid treatment etc is not usually needed.

TED causes these problems, which can be scored  by the ophthalmologist.

1. dry irritable eyes
2. redness of the conjunctiva...the redness increases as the disease is more active
3. puffy lids...these become more puffy as the disease is more active
4. bulgy eyes (proptosis)
5. raised upper eyelids showing the white above the eye more than usual (lid retraction_
6. lid lag...when looking down the upper eyelids stay up
7. these can result in more serious problems
   • stretching and damaging of the optic nerve
   • the fat and muscles in the orbit swell can can compress the optic nerve
   • if the eyes bulges a lot the cornea can become very dry and perforate
8. problems with eye movements causing double vision etc

Some of these problems get significantly worse when the condition is active, and anti-inflammatory steroid treatment etc may be needed. But some TED problems are not caused by 'active' inflammation, so that anti-inflammatory treatment is not effective and may not be needed, and some of these problems can be treated with surgery.

For example, the inflammation can cause the eyes to bulge forward, as the tissues in the eye swell. Anti-inflammatory treatment at this stage may reduce the swelling and the eyes will stop bulging. But if the treatment is given late, of if the condition is severe, the inflammation may have disappeared, but the bulging may remain, and surgery may needed to reduce the bulging.

Similarly, eyelid changes in the condition may remain after the 'inflammation' has gone, and the condition is said to be 'stable. Generally eyelid surgery is not carried out until the condition is stable and all the inflammation had stopped.

Explained in more detail here.

The thyroid and eye part of TED may not occur at the same time. TED can occur many years after the thyroid problem, and alternatively TED may develop years before the thyroid hormone problems themselves are present.

More commonly though, TED occurs a few months/a couple of years after the thyroid and thyroid hormone problem.