Thyroid Eye Disease

“Not an Incurable Disease Anymore!?
Treatment for Graves’ Ophthalmopathy
The Philosophy of Oculofacial Clinic Tokyo”

Surgery for Graves’ Disease
and Thyroid Eye Disease

Advantage of Our Method

1. Only excess fat is removed
2. No incision of the skin
3. Outpatient surgery
4. Simultaneous surgery
   on both eyes

The orbital fat decompression surgery conducted at our clinic is a culmination of global expertise, incorporating cutting-edge medical knowledge acquired through studying in the United States and insights gained from renowned international experts. This surgery is meticulously performed in a Japanese style using microscopes to further minimize damage to essential tissues.

There are no medical institutions worldwide conducting this surgery.

Day surgery is possible

This surgery involves removing only the excess fat while avoiding nerves and blood vessels related to visual function, requiring highly delicate and specialized techniques. Decompression surgery involving bone removal was developed because there have been no technique to remove fat while avoiding nerves and blood vessels, but it requires significant physical burden due to bone removal, and hospitalization for 1-2 weeks is necessary due to postoperative pain and bleeding.

With our clinic’s orbital fat decompression surgery, both eyes can be operated on simultaneously under general anesthesia on an outpatient basis, allowing patients to return home on the same day. This minimizes the impact on work and home life. If you are troubled by your condition, we hope you will consider our clinic’s orbital fat decompression surgery.

*1:We offer treatment at a discounted rate for those willing to cooperate with us by allowing photography before and after the procedure, as well as video recording during the surgery, for publication on our website.

Graves’ disease and thyroid eye disease exhibit
significant differences
in facial appearance before and after treatment.

This woman underwent the following treatments since the onset of Graves’ ophthalmopathy:

• Steroid pulse therapy
• Orbital decompression surgery
• Additional fat removal
• Strabismus surgery
  (performed at another clinic)

Mainly, the above treatments were administered.
When comparing before and after treatment, you can see a significant improvement, and her facial appearance looks completely different.

Facial profile

The difference before and after treatment is clear from surgery, and you can regain the beautiful facial features you had before onset.

It seems that Graves' ophthalmopathy was once called the "beautiful woman disease," but looking at this case, it's clear that the idea that "onset makes one beautiful" is a misconception.

Many celebrities have received treatments at our clinic.

Significantly improved with
the latest surgical technique, “orbital decompression surgery.”

Dr. Takako Yoshida,
Director of Shibuya Skin Clinic

Dr. Takako Yoshida was diagnosed with Graves’ disease at the age of 31 and subsequently developed thyroid eye disease as a complication, suffering for about 16 years.

In September 2020, she underwent surgery for thyroid eye disease at our clinic, which was successfully completed. There is a blog post about this experience, so please feel free to read it.

You can read the blog here.

There are mainly three types of surgical methods.

1. Orbital decompression
2. Strabismus surgery
3. Eyelid surgery

If medical treatments such as corticosteroids or radiation therapy are ineffective, surgery may be necessary. Below, I will explain the three surgical methods.

1.Orbital decompression

What is
orbital decompression surgery?

Orbital decompression surgery involves the removal of fat and soft tissue or bone around the eyes to reduce the protrusion of the eyeball. This surgery removes tissue behind the eyeball, and the procedure varies depending on the part removed.
The eyeball and muscles cannot be removed, so the removable parts are the increased fat and bone.
The bones are divided into four directions: upper, lower, inner, and outer. Of these, the upper is close to the brain and has less decompressive effect, so it is usually not performed. The surgery typically involves the inner wall, lower wall, and outer wall.
As for the fat, it is scattered around the eyeball, muscles, and nerves.

Among these, the removal of orbital fat and the outer wall of the orbit has an incidence rate of new diplopia of about 3%, but for the inner and lower walls, it ranges from 10-50%, known for a higher incidence of new diplopia.
The bones of the inner and lower walls are thin, making them easy to remove, but this also means a higher risk of diplopia, which can interfere with daily activities.
Furthermore, since the cheek's sensory nerve runs through the lower wall, there is a high possibility of causing numbness in the cheek.

Minimizing the burden on the body.

On the other hand, while the incidence of new diplopia is low in the removal of the lateral wall of the orbit, it is close to the brain and vital nerves and blood vessels of the eye, requiring specialized knowledge and experience to perform. Only skilled surgeons can perform this surgery.

The orbital fat decompression surgery performed at our clinic is conducted in a way that minimizes the burden on the body. We prioritize the removal of orbital fat as the first choice of surgery and avoid removing the lower and inner walls, which frequently cause diplopia, in an effort to reduce the incidence of diplopia. Also, these surgeries are primarily performed through the conjunctiva behind the eyelid or within the wrinkles of the skin, so there are almost no visible scars left. Furthermore, to reduce the number of surgeries, we perform simultaneous bilateral surgery. Local residents can go home on the same day, but for those from afar, we recommend staying at a nearby hotel after the surgery.

Surgical methods
at the Oculofacial Clinic.

The primary surgical methods at the Oculofacial Clinic involve the removal of orbital fat and the shaving of the outer wall as the first choices, aiming to reduce the incidence of diplopia by avoiding the removal of the lower and inner walls, which frequently cause diplopia.
Additionally, these surgeries are performed through incisions made in the conjunctiva behind the eyelid or within the skin’s wrinkles, resulting in minimal scarring.
To reduce the number of surgeries, bilateral simultaneous operations are performed.
Local residents may return home the same day, but for those from afar, staying at a nearby hotel post-surgery for one night only is recommended.

The day after
orbital decompression!
Orbital fat decompression is the best
for protruding eyeballs due to Graves’ disease!

Illustration of the orbit.

Illustration of the orbital bones 1.

The orange represents the inner wall of the orbit, and the yellow represents the lower wall of the orbit.

Illustration of the orbital bones 2.

The blue represents the outer wall of the orbit, and the purple represents the upper wall of the orbit. The green is the greater wing of the sphenoid bone, which is often removed when excising the outer wall.

The condition the day after surgery.

In the case of surgery performed through the lower eyelid conjunctiva, bruising centered around the lower eyelid occurs.

The bruising heals in about three weeks.
The swelling of the eyelid is not prominent.

2.Strabismus surgery

In Graves' ophthalmopathy, the muscles that move the eyeballs become enlarged and stiff, which can cause the two eyeballs to look in different directions.

Strabismus surgery involves manipulating the muscles that move the eyes to align the direction in which both eyeballs look. Our clinic does not perform this surgery; we often refer patients to specialist hospitals.

3.Eyelid surgery

This is
the final stage of treatment
for Graves’ disease and thyroid eye disease.

This choice is made after orbital decompression surgery or strabismus surgery.
In Graves' ophthalmopathy, the upper eyelid may retract, a condition known as eyelid retraction, and this surgery is performed last. Depending on the condition, the surgery may be performed not only on the upper eyelid but also on the lower eyelid.

Additionally, the removal of increased fat in the eyelids may also be performed. In cases where eyelash inversion occurs due to eyeball protrusion, surgery to correct this may also be carried out.

Examples of surgeries for
Graves’ disease and thyroid eye disease.

Female 20s.

This is a photo
before the onset.

The patient came to the clinic primarily complaining about changes in facial appearance and asymmetrical protrusion of the eyeballs.

Comparison pre and post surgery

Significant improvements
have been made.

From the pre-onset facial appearance, it is evident that there was a significant change to the pre-surgery appearance. The right eye is much more open, and there is a substantial increase in the exposure of the whites of the eyes both above and below. This has resulted in an asymmetrical facial appearance.

After undergoing orbital decompression surgery, there is a considerable improvement in facial appearance. Further decompression could have been performed, but since significant improvements were achieved and the patient was satisfied, the treatment was concluded.

Female 40s.

The patient came to the clinic with bilateral eyeball protrusion and retraction of the upper left eyelid.

Comparison pre and post surgery

The patient’s expression has improved to
a more gentle and soft appearance.

In this case, the left eye exhibited strong eyeball protrusion with visible exposure of the whites of the eyes both above and below. The asymmetry in protrusion resulted in a very pronounced asymmetry in facial appearance.

Orbital decompression surgery was performed to address this condition, followed by eyelid retraction surgery. After the surgeries, the eyeball protrusion improved, the widened appearance of the eyes was corrected, and the patient’s expression became gentler.

Female 30s.

This is a photo before the onset.

The patient came to the clinic primarily complaining about changes in facial appearance and asymmetrical protrusion of the eyeballs.

Comparison pre and post surgery

The swelling of the eyelids has disappeared.

It is evident that the orbital decompression surgery has resulted in a more beautiful facial appearance. Physically, the puffiness of the upper eyelids has disappeared, and the double eyelid lines have become more defined.

Female 40s.

Orbital decompression surgery was performed.

Comparison pre and post surgery

The swelling has gone down.

It can be observed that the swelling of the upper and lower eyelids, which was present preoperatively due to Graves’ ophthalmopathy, has disappeared postoperatively. Reduction in proptosis also improves dry eye symptoms such as redness, grittiness, and tearing.

Dark circles under the eyes caused by Thyroid Eye Disease can also be treated.

In our practice, orbital fat removed during orbital decompression surgery is grafted into the dark circles, thereby removing the dark circles under the eyes almost completely.
Thyroid eye disease can cause the eyes to appear open, which is called eyelid retraction. Eyelid retraction appears primarily on the upper eyelid, but some patients develop it on the lower eyelid.

This is also slightly improved by orbital decompression, but can be further improved by fat grafting.

Cases of Thyroid Eye Disease

Orbital Decompression for people
without Graves’ disease

Effective for other
than Graves’ disease

Orbital decompression can also be performed for eye protrusions that are not caused by Graves’ disease.

If the protruding eyeball causes disfigurement, rabbit’s eye or dry eye, surgery is indicated.

Available for revision surgery after surgery at other hospitals

You may notice that the upper eyelid bulge is improved and the double eyelid is deeper after orbital decompression.

We can also handle cases such as failures at other clinics and cases that need to be redone, so if you have any problems, please come in for a consultation first.

Medical Expenses

*1:We offer treatment at a discounted rate for those willing to cooperate with us by allowing photography before and after the procedure, as well as video recording during the surgery, for publication on our website.

Risks associated with this treatment and their incidence

• Internal bleeding may occur at the wound site due to surgery. At first, internal bleeding looks like a red bruise, but it turns yellow and moves downward under the skin due to gravity, disappearing in about 3 weeks. The swelling will mostly subside within the first two weeks. It takes about six months for complete disappearance. If a hematoma forms in the wound, surgery is required to remove it.
• If there is no diplopia before surgery, eye movement disorders will appear after surgery, resulting in double vision. It often disappears by the next day, but it may remain.
• If diplopia remains, it will gradually improve over 3 to 6 months, but diplopia remains in 0-3% of cases with lipectomy alone, 3-6% with lateral walls, and 10-65% with medial walls. It is said that then. In that case, strabismus surgery may be necessary. Even if double vision does not appear in frontal vision, there is a 10% chance that double vision will remain in peripheral vision (up, down, left, and right).
• After the surgery, your pupils may dilate or it may become difficult to see up close, but this will gradually improve over about six months.
• If damage occurs to the important nerves related to the eye or the blood vessels that feed them, vision and visual field problems may occur, leading to blindness. The incidence is approximately 1%, including mild cases.
• Since the surgery is performed close to the brain, infection can lead to serious conditions.
• The scar will gradually become less noticeable after surgery, but it may become noticeable or become a keloid. If the wound disintegrates after surgery, suturing will be required again. Orbital cellulitis may occur due to infection.