Patient information — Thyroid eye disease

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Before the operation

Avoid aspirin or ibuprofen-type medication (non-steroidal anti-inflammatory medication) for approximately two weeks before surgery, as this can increase any tendency to bruise. If you take aspirin regularly for medical reasons, please consult Mr Malhotra about whether it is safe to discontinue use.

It is advisable to stop smoking at least three weeks before surgery and not to smoke until at least two weeks after wounds are fully healed. Nicotine closes the blood vessels responsible for bringing oxygenated blood — vital for healing — to the tissues. Oxygen also fights infection and helps to keep tissue alive, as well as being instrumental in delivering important medications, such as antibiotics. Smoking clogs the lungs and therefore increases risk of pulmonary infections, such as pneumonia.

On the day of surgery

Dress casually
Wear slip-on shoes and a top that buttons down the front
Do not wear jewellery
Thoroughly wash your face
Don't wear make-up
No contact lenses
Discuss your oral medications with Mr Malhotra — they can usually be taken with a sip of water

If your operation is scheduled for the morning:

Do not eat or drink anything after 12 midnight the previous night — do not have breakfast.

If your operation is scheduled for the afternoon:

Have an early, light breakfast — do not eat or drink anything after 7.30am.

After surgery

Eyelid swelling and bruising may seem to be worse the day after surgery and the discolouration may run down your face from your cheeks to your chin. Both are normal and will soon fade.

Do

Ensure that someone takes you home and stays with you for at least 24 hours.
Rest quietly all day after surgery.
Watch television if you want.
Within two hours of surgery, begin taking paracetamol tablets every four hours for 48 hours, even if you seem to have no discomfort. Do not wake yourself up in the middle of the night to take paracetamol — if you do wake up, take two tablets to help you sleep without discomfort.
Take two paracetamol tablets as soon as you wake in the morning — take two more every four hours.
Be sure to follow instructions about other pain or anti-inflammatory medication.
Sleep propped up on two or three pillows to keep your head elevated.
Resume taking any medications your normally use, in your regular routine immediately after surgery.
Bathe the eye area, if necessary, with cooled boiled water and a clean tissue.

Don't

Drive immediately after surgery — before you start driving again, check that you can see a number plate clearly at 20 metres, which is a legal requirement.
Stay in bed unless you want to — a comfortable armchair is okay.
Take a shower or a bath for the first day — have a sponge bath instead, if necessary.
Have hot drinks or hot food immediately after surgery and until the following day.
Try to bend over much for the first two days after surgery — if your eye is patched, try not to put your head below your chest for three days.
Try to move your eyes around much — this will lessen the amount of general discomfort you may have.
Do any heavy work, lifting, running, gym work-outs or swimming for four weeks — check with Mr Malhotra before resuming any exercise schedule.

The technique involves minimally invasive surgery, usually through a small skin-crease incision. It involves expanding the bony walls of the eye socket (orbital cavity) and is often combined with removal of some orbital fat.

The most common complication is of new or worsening pre-existing double vision, known as diplopia. This has been reported in up to 15 per cent of cases. The risk of blindness is less than one in 600.

Double vision that persists may be either controlled with prisms or require eye muscle surgery (strabismus surgery) in order to align both eyes better. This is usually performed as day case surgery.

Medications

Oral Antibiotics: You may be prescribed oral antibiotics, such as Augmentin (co-Amoxiclav) tablets. Take them the following day after surgery, three times a day for seven days. Oral antibiotics are only prescribed in selected cases and not following routine eyelid surgery.

Eye pad

You may have a pad on your eye:

Do not remove it until advised by Mr Malhotra.
If the pad becomes loose, apply more tape. Do not remove the pad.
While the pad is on, do not get it wet. Shower from the neck down or take a bath.
Once you have removed the pad, you may shower and wash your hair.
Avoid getting too much soapy water in or around your eyes and the operated area.

Using the eye mask:

The eye mask should be applied before using the eye ointment.
It is not necessary to use anything sterile to apply a compress.
Use the eye mask provided according to instructions only. Never apply the eye mask directly to your eyes. Wrap it in a clean washcloth, small towel, piece of cotton or lint if you don't have any of these, a pad of tissues or paper towels will do.
The eye mask is filled with a non-toxic gel in a non-PVC casing. If the contents come into contact with your eyes you should wash them with cold water immediately. If there is any irritation or redness, contact Mr Malhotra or the hospital.

Using the eye mask cold

Place the eye mask in the refrigerator for one hour — for an extra-soothing effect, put it in the freezer for 10-15 minutes
Do not allow the mask to freeze solid.
Apply the wrapped eye mask to the operated eye(s) — keep the eye(s) closed.
Use 6-8 times a day — as often as you can tolerate.
Keep the mask on for 10-15 minutes each time.
Begin immediately after the eye pad has been removed to help decrease swelling.
Sleep on at least 2-3 pillows, if possible, to keep your head elevated.
Continue for a week, then switch to warm compresses.

Using the eye mask warm

Start using the eye mask warm compresses after discontinuing the use of a cold eye mask.
Soak the eye mask in water that is hot to the touch for 5-10 minutes.
Check the mask isn't too hot or too cold by pressing it against the back of your hand before you apply the mask to your face.
Apply the wrapped eye mask to the operated eye(s) &mdash keep the eye(s) closed.
Use 6-8 times a day &mdash as often as you can tolerate.
Keep the mask on for 10-15 minutes each time.
Observe any swelling and report if it is getting worse.
Observe for discharges around the suture line and bathe eyelids.
Apply the ointment according to Mr Malhotra's instructions.
Sleep on at least two to three pillows, if possible, to keep your head elevated.

Frequently asked questions

The doctors tell me my thyroid is now normal after treatment. Why are my eyes playing up?

With TED, the immune system pushes the thyroid gland to secrete too much hormone. This results in nervousness, palpitations, weight loss, diarrhoea, tremors, and a feeling of being hot all the time. Treatment is aimed at limiting the thyroid gland’s ability to make thyroid hormone.

This does not, however, affect the primary auto-immune process and the immune system may continue to target other tissues – in particular the muscles that control movement of the eyeball within it socket (extraocular muscles). The eye and socket (orbit) changes must be treated separately.

The steroids made my eyes much more comfortable. Can I just continue taking them?

Steroid therapy may be effective in halting the TED inflammatory phase and partially shrinking the muscle swelling but steroid side effects are very common with continued treatment.

If there are still problems with eye movements (double vision), problems of exposure to light (irritation and grittiness) or decreased vision then other medical treatments or surgery should be considered.

Can my eyelids be dealt with first?

It is possible to consider eyelid surgery first if you do not wish to undergo orbital decompression and your double vision is not too bothersome.

However, as a rule, because orbital decompression can cause double vision by altering the position of the eye muscles and eye muscle (strabismus) surgery may change the eyelid position, we advise that eyelid surgery should be carried out after any possible orbital decompression or eye muscle surgery.