Rare Thyroid Eye Disease Often Occurs Alongside Hyperthyroidism
Dear Doctors: Lately, we’ve been seeing a lot of ads on TV for a medication to treat thyroid eye disease. My daughter, who is 23, suffers from dry eyes, and now she’s sure she has it. What is thyroid eye disease? How do you get it, and how is it diagnosed?
Dear Reader: Thyroid eye disease is actually quite rare. Here in the United States, the incidence rate is about 19 cases per 100,000 people. It is more than four times as common in women as it is in men.
Most cases of thyroid eye disease occur in conjunction with hyperthyroidism, a term that means the thyroid gland has become overactive. A common cause of hyperthyroidism is Graves disease, an autoimmune disease that primarily affects the thyroid gland. The immune system mounts an attack on the tissues of the thyroid gland, which causes it to become hyperactive.
The most common symptom of thyroid eye disease is a retraction of the eyelids, resulting in the appearance of bulging or staring eyes. Additional symptoms can include:
▪ Blurred or double vision that does not improve when you blink.
▪ Persistently dry or watery eyes.
▪ A feeling of grittiness in the eyes.
▪ Redness in the eyes or the eyelids.
▪ Swelling or fullness in one or both upper eyelids.
▪ Pronounced bags beneath the eyes.
▪ Pain in or behind the eyes (particularly when looking to the edges of one’s vision).
▪ Difficulty in moving the eyes.
▪ Difficulty tolerating bright light.
The physical changes caused by thyroid eye disease can adversely affect vision and even lead to blindness.
Diagnosis begins with a physical examination of the eyes, including the eyelids. The disease can increase the pressure within the eye. This puts the individual at risk of glaucoma, so a test of intraocular pressure may be requested.
If the collection of physical symptoms suggests thyroid eye disease, the next step is blood tests to check the person’s levels of thyroid hormones. Imaging tests of the eyes may be used.
The disease typically occurs in two phases. An initial active phase, marked by ongoing inflammation, lasts from several months to several years. This is followed by a so-called inactive phase, when inflammation has subsided, but symptoms are still present.
Because thyroid eye disease is a complex and multisystemic condition, a group of specialists often work together in its diagnosis and management. This often includes an ophthalmologist, an endocrinologist and an otolaryngologist (or ear, nose and throat specialist). It is advised that each of these specialists have an expertise in thyroid eye disease.
There is no known cure for the condition at this time. That means treatment focuses on managing existing symptoms and monitoring their effect on vision.
The goal in treating thyroid eye disease is to ease discomfort, protect the cornea and preserve sight. Over-the-counter eye drops are often used to ease dryness. Newer medications to ease inflammation, which fall into a class of drugs known as monoclonal antibodies, may also be prescribed.
If your daughter’s symptoms suggest she may have thyroid eye disease, she should see her health care provider to begin the process of diagnosis.
Oxygen Therapy May Help People With Cluster Headaches
Dear Doctors: I get crushing headaches every fall, which I’ve always assumed are part of having allergies. But a specialist at our local medical center diagnosed me with cluster headaches. She says oxygen is a good therapy. What about meds? This is all new to me, and any information will be helpful.
Dear Reader: Cluster headaches are a severe form of headache in which pain is concentrated on one side of the head. Your use of the word “crushing” is not an exaggeration, as these types of headaches are notoriously painful. The attacks, which typically last from one to three hours, occur in groups, or clusters. They can arise repeatedly throughout a single day, or they may recur every few days.
Cluster headaches can also occur in regular cycles, as has happened in
your case, arising at certain times of year. The cycles can last for several weeks or several months. This can lead to these types of headaches being mistakenly linked to other health conditions, such as allergies.
The cause of cluster headaches is not yet clear. They are fairly rare, affecting just 0.1% of the population, which makes them difficult to study. Due to their cyclic nature, the region in the brain that oversees the body’s biological clock, known as the hypothalamus, is believed to play a role. Cluster headaches occur more often in men than in women, and studies suggest a genetic component may be involved.
Nasal congestion, watery eyes and inflammation of the blood vessels that serve the eye area often accompany these headaches. Diagnosis involves a detailed review of the person’s symptoms and medical history. Additional tests, including brain scans, are often used in order to exclude other potential causes.
Treatment focuses on easing pain during a headache, and on preventing future attacks. The oxygen therapy your doctor recommended is the most common approach to treating this type of headache pain. The oxygen, at 100% concentration, is delivered via a face mask at the first signs of pain. It is estimated that 75% to 80% of patients report complete relief from pain after 15 to 20 minutes of
oxygen treatment. Oxygen therapy has no side effects and is readily available in emergency rooms and many urgent care clinics. An oxygen cannister can also be kept at home. While effective for cluster headaches, oxygen therapy does not offer similar relief for migraine.
When oxygen is not available, a class of drugs known as triptans are often prescribed. For swift absorption, these are administered as a nasal spray or injection. Unfortunately, over-thecounter pain medications are not effective. Neither are medications
that contain narcotics. In fact, medications that contain narcotics may generate additional attacks.
Prevention involves identifying and avoiding potential headache triggers, particularly during a known cycle. These can include alcohol, bright light, cigarette smoke, powerful scents and changes in altitude. Galcanezumab, a migraine drug, and the blood pressure medication verapamil may help prevent cluster headaches. Steroids, such as prednisone, may help extend periods of remission. Now that you have
an accurate diagnosis, your doctor will advise you on the best treatment regimen.
Eve Glazier, M.D., MBA, is an internist and associate professor of medicine at UCLA Health. Elizabeth Ko, M.D., is an internist and assistant professor of medicine at UCLA Health. Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.