The Case: 

• Jane has been experiencing dry, irritated eyes for the past 2 years
• She’s treated them with steroid drops and antihistamines but the problem persists
• After consulting many doctors and taking tests, there seem to be no answers. 

 

Eye irritations can range from dry, itchy eyes to puffiness. Most people reach for over-the-counter eye drops or antihistamines for temporary relief. If it’s caused by the environment or allergies, this might solve the issue but when it persists - there may be a bigger issue at play. 

 

The Investigation

My sense was that another organ was driving her eye issues. I suspected that it actually wasn’t  an eye issue, so to solve this health mystery, we had to look outside the box. And, I knew just who to contact, Dr. Rudrani Banik (Dr. Rani). She’s a board-certified and fellowship-trained Neuro-Ophthalmologist with a functional medicine approach. You may remember her, she was on episode 50. 

Dr. Rani confirmed that eye issues aren’t always just about the eyes. 

 

The Eye Thyroid Connection

The thyroid is related to the health of your eyes. The receptors on the thyroid look very similar to the receptors that are found on the connective tissue in the eye socket. When there are issues with the thyroid, specifically autoimmune issues, there is the possibility that the eyes can be affected. There are a lot of different eye issues that are related to either Graves Disease or Hashimoto’s (autoimmune issues related to the thyroid).  However, sometimes the eye issues present before the autoimmune issue is detected or diagnosed making the connection difficult to make. 

 

Symptoms of Thyroid Eye Disease

The symptoms of thyroid eye issues can start out like many eye issues. For example, you might have dryness, irritation, redness, puffiness or swollen lids. The usual course of action for these symptoms might be to use drops (including over the counter and steroid gel drops), antihistamines or both but if these don’t work, these may be symptoms of thyroid eye disease. 

Additional characteristics of thyroid eye disease may include the swelling or puffiness of the upper eyelids especially in the morning with the swelling decreasing through the day. Other symptoms may include chronic redness or a shift in the width of the eye socket. The latter may result in the eyes appearing bigger or wider. There may even be some inflammation causing the eyes to protrude or bulge (proptosis). 

If left undiagnosed and untreated, the muscles behind the eye socket can get involved and cause double vision and even vision loss. Note that this does not happen overnight - it’s a severe advancement of the condition but it’s worth noting what can happen if the situation is not dealt with. 

 

Diagnosing Thyroid Eye Disease

The most important part of tying an eye issue to the thyroid is to get blood tests.  But, it’s not enough to just test the TSH or T3 as many doctors will do as a thyroid test. Dr. Rani says she likes to get the full antibody panel including TPO (thyroid peroxidase), Tg (thyroglobulin  antibodies), and TSH (thyroid-stimulating hormone) receptor (which tends to be elevated in thyroid eye disease patients).   

Dr. Rani also says an eye exam is very important. She measures the lids very carefully to see if they are more open. She also tracks this over time to watch for changes. She’s also looking for congestion in the eye socket, asks about double vision, and checks the ocular motility.  Finally she uses an exophthalmometer to determine how the eye rests within the socket. Sometimes a CAT scan or MRI are required. 

 

Treatment of Thyroid Eye Disease

Once the issue has been properly diagnosed, there are several things that can be done to help treat thyroid eye disease including:

 

 

• Eye Lubrication 

 

Treating eye redness, dryness, and irritation can be done with topical medications (typically drops or ointments). Sometimes patients require medications (antihistamines or topical steroids but Dr. Rani only uses steroids in extreme cases (when vision is at risk) because there is a risk of side effects like developing glaucoma or herpetic infections. 

 

 

• Diet Changes 

 

Certain foods may be triggering thyroid issues (for example, gluten, dairy, and goitrogens like cruciferous vegetables). Avoiding these foods may help. 

 

 

• Avoid Smoke 

 

Dr. Rani says it's really really important to avoid any kind of smoke or fumes. Studies show that people who smoke have a much worse prognosis when it comes to thyroid eye disease, so it’s suggested that they quit smoking and even avoid secondhand smoke. Cooking fumes can even create a problem.

 

 

• Reduce Stress 

 

When it comes to managing the thyroid, stress is a major factor. Stressful periods can trigger thyroid issues so ongoing stress-management is important. 

 

 

• Selenium 

 

A European study found that selenium (a mineral) can reduce the symptoms of thyroid eye disease. In that study, they used a supplement (100 mcg twice per day) but selenium can also be found in Brazil nuts, eggs, beef, chicken, and pork. Selenium can also be helpful for the conversion of T4 to T3. 

 

• Zinc 

 

Zinc is really important for healthy thyroid function and producing hormones. You can take a zinc supplement, eat foods rich in zinc or do zinc lozenges. 

Treatment Cautions

There are a lot of eye drops for reducing dryness, redness and irritation but Dr. Rani encourages people to read the label. Look specifically for polyvinyl alcohol. It is a lubricant but the pH is not balanced to the eye so it can be very toxic to the surface of the eye and make dry eyes worse. Some brands that Dr. Rani says are free of alcohol are Refresh, Systane, and Genteel. 

 

Who to See - Optometrist vs. Opthamologist

Many people aren’t sure about the difference between an optometrist and an ophthalmologist - and who to see if they think they may have thyroid eye disease. Both are doctors but the optometrist is a doctor of optometry (OD) and must go to college for four years and then optometry school for four years. Ophthalmologists are MDs (medical doctors) with four years in school, four years in medical school and then an additional internship and residence (another four years). It’s training in both medical and surgical aspects of the eye. For thyroid eye disease, Dr. Rani says you would want to see an ophthalmologist because you may need to get special treatment which may include surgery.  

 

Mystery Solved

 Jane didn’t specifically present with many classic thyroid symptoms, but knowing the connection, I knew I needed to evaluate this further. Comprehensive lab tests revealed that Jane’s TSH, T4 and T3 were completely normal however her thyroid peroxidase antibodies (associated with Hashimoto’s) were 325. Ideally they should be below 35. We didn’t know how long her antibodies had been elevated but the good news was that (unlike many others with Hashimoto’s) her actual thyroid function had not been affected. The eye issues were the first symptom. .With the mystery solved, we knew we needed to address the immune system which was confused and attacking the thyroid and the eyes due to molecular mimicry. 

 

Next Steps 

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