You may attend an orthoptic clinic if:

• You are experiencing double vision (diplopia)
• You have had trauma/injury to the eye/eye area
• You have had a stroke which has resulted in eye problems
• You are experiencing field loss
• You have a turn in the eye (squint/strabismus) that may have been present in childhood
• You are struggle to focus/having trouble with reading

We work closely with other departments including Maxillo-facial, Neurology and Stroke.

Treatments may include:

• Prisms to help join the double vision
• Glasses to improve sight/prevent double vision
• Exercises/Eye Training to aid rehabilitation

Introduction

This leaflet provides you with information on Fresnel Prisms.  It is not meant to replace the discussion between you and your Doctor/Healthcare Professional but may act as a starting point for discussion.

If after reading it you have any concerns or require further explanation, please discuss this with a member of the Healthcare Team who has been caring for you.

What is a fresnel prism?

It is a thin transparent piece of plastic which is usually fitted to the inside of the lens of your glasses. This can correct double vision by bending the light before it enters you eye to move the 2 images back together.

How often do I need a new fresnel prism?

This varies and it will need to be changed if it no longer joins your double vision or if the plastic of the prism has aged and is less clear to see through.

Will I always need fresnel prisms?

The majority of people can be weaned off prisms. Alternatively, a small amount of prism can be  permanently incorporated into your glasses lens.

If the angle of the prism is too large, then either surgery or long term fresnel prisms may be an option.

What are the side effects?

You may notice a rainbow effect on the edge of things at times and there is slight reduction in vision when looking through the prism.

Fitting a fresnel prism

The prism is normally fitted by the Orthoptist. 

If you are not able to attend the hospital to have it fitted however, it may be necessary for you to fit a replacement prism yourself. 

You can use the old one as a template. If you need any help, please call us.

Cleaning your Fresnel prism

· The fresnel prism can be cleaned as you normally clean your glasses with a soft, dry cloth.

· You can use a soft toothbrush or nailbrush to gently remove dust from the ridges of the prism.

· You can occasionally thoroughly clean your prism and glasses with warm water.

· You can remove your prism by placing your finger nail between the prism and the lens of your glasses and prising it off, then washing it with warm water and soap.

What should I do if my double vision returns whilst wearing the prisms?

Please contact us and we will re-assess your requirements.

Introduction

This leaflet provides you with information on Myasthenia Gravis (MG).  It is not meant to replace the discussion between you and your Doctor/Healthcare Professional but may act as a starting point for discussion.

If after reading it you have any concerns or require further explanation, please discuss this with a member of the Healthcare Team who has been caring for you.

What is Myasthenia Gravis (MG)?

· Myasthenia Gravis (MG) is a condition which causes muscles to fatigue or tire quickly, caused by antibodies reducing the signal between nerves and muscles.  As the signal is not getting to the muscles, they become weak and easily tired.

· Sometimes it only affects the eye muscles (Ocular MG), or it can affect other skeletal muscles in the body (Generalised MG).  If MG is generalised it can lead to weakness of limbs, problems swallowing, speaking or breathing.

· It is typical for symptoms to be variable and worse after using the muscles or when you are tired.

How can Myasthenia Gravis affect my eyes?

Typically, MG leads to droopy eyelids or double vision due to weak eye movement muscles.

Will it get better?

With treatment the symptoms of MG can be improved.

Will I need more tests?

The blood test may show if antibodies are present. Some people who do have MG have normal blood results.

An ice pack can be used to see if the muscle function improves when cold. This is typical of MG.

Sometimes an injection is given to see if muscle function improves temporarily and also suggests you have MG.

Tests that measure electrical activity in muscles may also be required.

It is necessary for some patients to have scans if the diagnosis of MG is not clear.

What are the treatment options?

· A Neurologist will consider treating MG with Pyridostigmine which is a drug that increases the              substance that carries the nerve signal to the muscle (called acetylcholine).  This can balance out the effect of the antibodies and reduce muscle fatigue.

· Alternatively immunosuppressant drugs may be used to reduce antibody production. 

· Surgically remove the thymus gland to reduce any antibodies.

Treatment for conditions caused by MG

Droopy eyelid. 

You may choose to leave it covering one eye as it can eliminate any double vision.

Double vision. 

This is caused because your eyes no longer move and work together. The type and severity of the double vision will vary between people.  Patching or blurring one eye can be useful to improve double vision.

Using Prisms to correct double vision

Prisms bend light to move the displaced images closer together so can sometimes be used to join double vision back to single. 

Prisms come in different strengths and the Orthoptist will assess which is the best one for you. 

Initially you will be given a temporary prism which will be stuck onto your own glasses or a plain pair of glasses from the hospital.  Long term some prisms can be incorporated into your glasses lens if they are still required.

Introduction

This leaflet provides you with information on Orbital Blow-out Fracture.

It is not meant to replace the discussion between you and your Doctor/Healthcare Professional but may act as a starting point for discussion.  

If after reading it you have any concerns or require further explanation, please discuss this with a member of the Healthcare Team who has been caring for you.

What is an Orbital Blow-out Fracture?

· An orbital blowout occurs when an injury causes fractures to the bones of the eye socket (orbit). 

· The trauma may affect the orbit directly or indirectly.

· The eye movement muscles or soft tissue within the orbit can become trapped or damaged in these fractures. 

· There is typically lots of swelling of these soft tissues and muscles due to the injury.

How can Orbital Blow-out Fracture affect my eyes?

· Double vision can occur if the eye movement muscles are affected or damaged.

· It is common to feel pain on attempted eye movement.

· Vision can be affected by trauma to the eye itself or the optic nerve. 

· You may have blurry vision if the muscles that focus the lens are affected.

· Sometimes the eyeball can be displaced (usually backwards) if some of the soft tissue from the orbit drops down through the fractures.

· You can have changes in the sensation of the cheek or teeth if the infraorbital nerve (that lies at the bottom of the eye socket) is damaged.

· It is likely that bruising will be present and haemorrhages may be present in the eye.

· Sometimes double vision occurs due to soft tissue swelling only and this recovers on its own.  This may take several weeks.

· In the short term an eye patch or prism can improve the double vision.

· More severe blow-out fractures require treatment to get better.

· Recovery can be complete or partial. In a partial recovery some muscle weakness is still noticeable long term.

Will I need more tests?

· It is likely you will need imaging of the orbit (CT or MRI), to assess the presence of the severity of fractures.  It will also show how much the eye muscles and soft tissue are involved.

· You will probably need to be seen by the Maxillofacial team who will carry out tests.  Your vision and eye movements will be checked as well as the structures at the back of the eye. 

· The tests may need to be repeated once some of the swelling has gone down.

· You will need to have the structures at the back of the eye checked.

What are the treatment options?

· A blowout fracture can be repaired surgically to free any trapped tissue and reconstruct the bones of the orbit.  This is not always necessary and the maxillofacial team (who specialise in orbital and facial fractures), will discuss with you whether your fracture needs an operation to repair it or not.

· Patching or blurring one eye can be useful to improve double vision, especially soon  after the injury when things may be changing quickly.

· Some people can control their double vision better by putting their head in a different position.  You might do this without realising and your Orthoptist can give you advice about it.

Using Prisms to correct double vision

· Prisms can sometimes be used to join double vision back to single. 

· The prism bends light to move the displaced images closer together.

· Prisms come in different strengths. 

· At first you will be given a temporary prism which will be stuck onto your own glasses or a plain pair of glasses from the hospital. 

· Long term some prisms can be incorporated into your glasses lens (This would usually be  6 months or more after the injury).

Surgical correction of double vision

· In more severe orbital blow out fractures, permanent damage to the eye movement muscles can occur.

· There may be some residual eye muscle weakness after a period of recovery or the muscles may not recover.

· Surgery on the eye movement muscles can improve the double vision for some people.

· The success of the surgery will depend on how many muscles have been affected and to what extent they have been affected.

· The Orthoptist will check that everything is stable, measure the position and movement of the eyes and test to help predict the likely surgical outcome.

Introduction

This leaflet provides you with information on 3^rd Nerve Palsy.

It is not meant to replace the discussion between you and your Doctor/Healthcare Professional but may act as a starting point for discussion.  

If after reading it you have any concerns or require further explanation, please discuss this with a member of the Healthcare Team who has been   caring for you.

What is a 3rd Nerve Palsy?

The 3rd cranial nerve usually carries information from the brain to 4 of the 6 eye  movement muscles, the main eyelid muscle and the pupil.

A palsy is when the signal along the nerve is interrupted, causing weakness of the muscle(s) it usually supplies.

You can have a complete 3rd Nerve Palsy, when all 4 eye movement muscles, the eye lid and pupil are all affected.  A partial 3rd nerve palsy is when only one or more muscle is affected.

It is most likely to have a 3rd Nerve palsy affecting one eye, but it can affect both.

What causes 3rd Nerve Palsy?

A nerve palsy can be congenital (from birth) or acquired later in life.

There are various causes of acquired nerve palsies and the Orthoptist and Ophthalmologist will consider which is most likely in your particular case.

The possible causes include:

Microvascular:  A disruption of the blood supply to the nerve.  This can be due to diabetes, high blood pressure, high cholesterol or smoking.  The blood supply to the nerve can also be affected by stroke.

Trauma (head injury) causing damage to the nerve.

Inflammation of the nerve (due to infection or virus).

Space-occupying lesion:  This could be a tumour or aneurysm pressing on the nerve. Sometimes the lesion is not near the nerve, but it causes a build-up of pressure in the head that compresses the nerve.

Demyelination: Degeneration of the protective coating of the nerve which occurs in conditions like MS.

Surgery: Damage to the nerve can occur during surgery or due to post-op swelling.

Migraine: Ophthalmic migraines can occasionally cause nerve palsies.

How can 3rd Nerve Palsy affect my eyes?

Because the 3rd nerve controls several eye muscles it can affect the eyes in different ways.

It can cause a droopy eyelid and can also affect the position of the eye. This can lead to double vision if the eyes are no longer aligned together.  Because the pupil may be affected, this can lead to light sensitivity and blurry vision.

Will it get better?

This will depend on the cause.  Often, once the cause for the 3rd nerve palsy has been treated the function of the nerve improves.

Microvascular nerve palsies commonly recover on their own. This usually occurs in about 6 months or less.

Recovery can be complete or partial. In a partial recovery some muscle weakness is still apparent long term.

Will I need more tests?

You will probably need tests to find out the cause of the 3rd nerve palsy.  This may include blood tests or scans.

The Orthoptist and Ophthalmologist will decide which tests you need, and refer you to other departments, such as neurology or stroke teams if necessary.

You will also need repeat Orthoptic testing. This is important to track any changes on your eye      muscles and eye position and find out if the 3rd nerve palsy is getting better or worse.

It is also helpful to do these tests to see how to best manage any symptoms you have.

What are the treatment options?

The condition or problem that has caused the 3rd nerve palsy may require treatment.  This will be different for each of the conditions and involve other specialists.

A microvascular 3rd nerve palsy sometimes does not require any active treatment, or it may have been caused by a condition for which you are already receiving treatment for example, high blood pressure tablets). 

Treatment for conditions caused by 3rd Nerve Palsy

Droopy eyelid: 

If you have got a droopy eyelid as a result of your 3rd nerve palsy, you may choose to leave it covering one eye as it can eliminate any double vision.  

If there is no recovery of the eyelid position, surgery or “ptosis props” can be considered to raise the lid.

Double vision:

Some people with 3rd nerve palsy have double vision because their eyes no longer move and work together.  The type and severity of the double vision will vary between people.

Short term double vision is eliminated by keeping the eyelid covering one eye or covering one eye with a patch or a blurred lens. This is usually the best option early on, especially if things are changing with your eyes.

Some people can control their double vision better if they adopt a compensatory head posture. You might do this without realising or your Orthoptist can give you advice about it.

Using Prisms to correct double vision:

Prisms can sometimes be used to join double vision back to single. The prism bends light to move the displaced (moved) images closer together.

Prisms come in different strengths. The best one for you can be assessed by the Orthoptist and it can be changed if your symptoms change.

At first you will be given a temporary prism which will be stuck onto your own glasses or a plain pair of glasses from the hospital. 

Long term some prisms can be incorporated into your glasses lens (This would usually be 6 months or more after the 3rd nerve palsy started.)

Because several eye movement muscles can be affected at the same time in a 3rd Nerve Palsy, it can be difficult to get the vision back to single with a prism.  This is because the misalignment of the eyes is different in different positions.

Surgical correction of double vision

If there is some residual eye muscle weakness after a period of recovery or no recovery has occurred, surgery on the eye movement muscles can sometimes improve double vision.

The success of the surgery will depend on how many muscles have been affected by the 3rd nerve palsy and to what extent they have been affected.

The Orthoptist will check that everything is stable, measure the position and movement of the eyes and test to help predict the likely surgical outcome.

What can I do to help prevent Nerve Palsy?

To help prevent further nerve palsies or microvascular problems, please visit your GP to ensure you are getting the best treatment possible for any other health condition(s) you may have.

It may also be appropriate to review your lifestyle to see if you can make any improvements that could contribute to better microvascular health, such as giving up smoking, doing more exercise or improving your diet.

Introduction

This leaflet provides you with information on 4th Nerve Palsy.

It is not meant to replace the discussion between you and your Doctor/Healthcare Professional but may act as a starting point for discussion.  

If after reading it you have any concerns or require further explanation, please discuss this with a member of the Healthcare Team who has been caring for you.

What is a 4th Nerve Palsy?

The 4th nerve usually carries information from the brain to the eye movement muscle, that moves the eye down and in towards the nose.

A palsy is when the signal along the nerve is interrupted, causing weakness of the muscle(s) it usually supplies.

You can have a complete 4th Nerve Palsy, where the muscle has no partial function where the muscle is weakened.

What causes 4th Nerve Palsy?

A nerve palsy can be congenital (from birth) or acquired later in life.

There are various different causes of acquired nerve palsies and the Orthoptist and Ophthalmologist will consider which is most likely in your particular case.

The possible causes include:

Microvascular:  A disruption of the blood supply to the nerve.  This can be due to diabetes, high blood pressure, high cholesterol or smoking.  The blood supply to the nerve can also be affected by a stroke.

Trauma (head injury) causing damage to the nerve. This is common for 4th nerve palsies because of the route the nerve takes.

Inflammation of the nerve (due to infection or virus).

Space-occupying lesion:  This could be a tumour or aneurysm pressing on the nerve. Sometimes the lesion is not near the nerve, but it causes a build-up of pressure in the head that in turn compresses the nerve.

Demyelination: Degeneration of the protective coating of the nerve which occurs in conditions like MS.

Surgery: Damage to the nerve can occur during surgery or due to post-op swelling.

Migraine: Ophthalmic migraines can occasionally cause nerve palsies.

Will it get better?

This will depend on the cause. Often, once the cause for the 4th nerve palsy has been treated the function of the nerve improves.

Microvascular nerve palsies commonly recover on their own. This usually occurs in about 6 months or less.

Recovery can be complete or partial.  In a partial recovery some muscle weakness is still apparent long term.

Will I need more tests?

You will probably need tests to find out the cause of the 4th nerve palsy. This may include blood tests or scans.

The Orthoptist and Ophthalmologist will decide which tests you need, and refer you to other departments, such as neurology or stroke teams if necessary.

You will also need repeat Orthoptic testing. This is important to track any changes on your eye muscles and eye position and find out if the 4th nerve palsy is getting better or worse.

It is also helpful to do these tests to see how to best manage any symptoms you have.

What are the treatment options?

The condition or problem that has caused the 4th nerve palsy may require treatment. This will be different for each of the conditions and involve other specialists.

A microvascular 4th nerve palsy sometimes does not require any active treatment, or it may have been caused by a condition for which you are already receiving treatment for example, high blood pressure. 

Treatment for conditions caused by 4th Nerve Palsy

Double vision:

Some people with 4th nerve palsy have double vision because their eyes no longer move and work together. The type and severity of the double vision will vary between people. Some people can control their double vision better if they adopt a compensatory head posture. You might do this without realising or your Orthoptist can give you advice about it.

Sometimes using a patch or clouded lens for one eye is more appropriate to get rid of the double vision, especially if the 4th is severe or things are changing with your eyes.

Prisms can be helpful in the short or long term.

Using Prisms to correct double vision

· Prisms can sometimes be used to join double vision back to single. 

· Prisms cannot be used for images that are tilted, so therefore prisms are not always suitable for people with a 4th nerve palsy.

· The prism bends light to move the displaced  images closer together.

· Prisms come in different strengths.  The best one for you can be assessed by the Orthoptist and it can be changed if your symptoms change.

· At first you will be given a temporary prism which will be stuck onto your own glasses or a plain pair of glasses from the hospital. 

· Long term some prisms can be incorporated into your glasses lens (This would usually be 6 months or more after the 4th nerve palsy started.)

Surgical correction of double vision

If there is some residual eye muscle weakness after a period of recovery or no recovery has occurred, surgery on the eye movement muscles can sometimes improve double vision.

The Orthoptist will check that everything is stable, measure the position and movement of the eyes and test to help predict the likely surgical outcome.

What can I do to help prevent Nerve Palsy?

To help prevent further nerve palsies or microvascular problems, please visit your GP.  This will ensure you are getting the best treatment possible for any other health condition(s) you may have.

It may also be appropriate to review your lifestyle to see if you can make any improvements.  These could contribute to better microvascular health, such as:

· Giving up smoking.

· Doing more exercise.

· Improving your diet.

Introduction

This leaflet provides you with information on 6th Nerve Palsy.

It is not meant to replace the discussion between you and your Doctor/Healthcare Professional but may act as a starting point for discussion.  

If after reading it you have any concerns or require further explanation, please discuss this with a member of the Healthcare Team who has been caring for you.

What is 6th Nerve Palsy?

The 6th cranial nerve usually carries information from the brain to the eye muscle, that pulls the eye away from the nose.

A palsy is when the signal along the nerve is interrupted, causing weakness of the muscle(s) it usually supplies.

You can have a complete 6th Nerve Palsy, where the muscle has no function or partial where the muscle is weakened.

It is most likely to have a 6th nerve palsy affecting one eye, but it can affect both.

What causes 6th Nerve Palsy?

A nerve palsy can be congenital (from birth) or acquired later in life.

There are various different causes of acquired nerve palsies and the Orthoptist and Ophthalmologist will consider which is most likely in your particular case.

The possible causes include:

Microvascular:  A disruption of the blood supply to the nerve.  This can be due to diabetes, high blood pressure, high cholesterol or smoking. The blood supply to the nerve can also be affected by stroke.

Trauma (head injury) causing damage to the nerve.

Inflammation of the nerve (due to infection or virus).

Space-occupying lesion:  This could be a tumour or aneurysm pressing on the nerve. Sometimes the lesion is not near the nerve, but it causes a build-up of pressure in the head that compresses the nerve.

Demyelination: Degeneration of the protective  coating of the nerve which occurs in conditions like MS.

Surgery: Damage to the nerve can occur during surgery or due to post-op swelling.

Migraine: Ophthalmic migraines can occasionally cause nerve palsies.

 Will it get better?

This will depend on the cause. Often, once the cause for the 6th nerve palsy has been treated the function of the nerve improves.

Microvascular nerve palsies commonly recover on their own. This usually occurs in about 6 months or less.

Recovery can be complete or partial.  In a partial recovery some muscle weakness is still apparent long term.

Will I need more tests?

You will probably need tests to find out the cause of the 6th nerve palsy.  This may include blood tests or scans.

The Orthoptist and Ophthalmologist will decide which tests you need, and refer you to other departments, such as neurology or stroke teams if necessary.

You will also need repeat Orthoptic testing. This is important to track any changes on your eye muscles and eye position and find out if the 6th nerve palsy is getting better or worse.

It is also helpful to do these tests to see how to best manage any symptoms you have.

What are the treatment options?

The condition or problem that has caused the 6th nerve palsy may require treatment. This will be different for each of the conditions and involve other specialists.

A microvascular 6th nerve palsy sometimes does not require any active treatment, or it may have been caused by a condition for which you are already receiving treatment for example, high blood pressure. 

Treatment for conditions caused by 6th Nerve Palsy

Double vision:

When one eye muscle becomes weak it can affect the balance of the eyes. Usually this causes double vision as the eyes cannot move and work together. 

The double vision may be constant or only present in a particular position.

The 2 images are usually side by side in a 6th nerve palsy.

Short term double vision is eliminated by or covering one eye with a patch or a blurred lens. This is usually the best option early on, especially if weakness is severe or things are changing with your eyes.

Some people can control their double vision better if they adopt a compensatory head posture. You might do this without realising.  Your Orthoptist can give you advice about it.

Using Prisms to correct double vision

· Prisms can sometimes be used to join double vision back to single. 

· The prism bends light to move the displaced images closer together.

· Prisms come in different strengths. The best one for you can be assessed by the Orthoptist and it can be changed if your symptoms change.

· At first you will be given a temporary prism which will be stuck onto your own glasses (or a pair of plain glasses provided by the hospital if you don’t have your own)  similar to the way a sticker is attached on a car windscreen.

· Long term some prisms can be incorporated into your glasses lens. This would usually be 6 months or more after the 6th nerve palsy started.

Surgical correction of double vision

If there is some residual eye muscle weakness after a period of recovery or no recovery has occurred, surgery on the eye movement muscles can sometimes improve double vision.

The success of the surgery will depend on the extent that the muscles were affected and how much recovery has occurred.

The Orthoptist will check that everything is stable, measure the position and movement of the eyes and test to help predict the likely surgical outcome.

What can I do to help prevent Nerve Palsy?

To help prevent further nerve palsies or microvascular problems, please visit your GP.  This will ensure you are getting the best treatment possible for any other health condition(s) you may have.

It may also be appropriate to review your lifestyle to see if you can make any improvements.  These could contribute to better microvascular health, such as:

· Giving up smoking.

· Doing more exercise.

· Improving your diet.

Introduction

This leaflet provides you with information on Squint Surgery.

It is not meant to replace the discussion between you and your Doctor/Healthcare Professional but may act as a starting point for discussion.  

If after reading it you have any concerns or require further explanation, please discuss this with a member of the Healthcare Team who has been caring for you.

Why do I need Squint Surgery?

This will vary between patients. Usually, it is to improve the alignment of the eyes. This can be helpful for psycho-social (cosmetic) reasons.

It may also reduce double vision for some patients.

What is Squint Surgery?

Squint surgery is a very common operation usually performed under general anaesthetic.

It is nearly always a day case procedure, and you will not need to stay in overnight.

It involves adjusting the eye movement muscles on the outside of the eye to strengthen or weaken them.

What is involved in Squint Surgery?

· Squint surgery involves shortening the muscle or changing where it is attached to the eye.

· The surgeon is able to access them without removing the eye from its eye socket, as the muscles are quite near to the front of the eye.

· Stitches are used to reattach the muscles in their new positions. These dissolve over time and do not need to be removed.

What are the different kinds of surgery?

Non-adjustable surgery

This is usually carried out under general anaesthetic (when you are asleep).  It takes around 1 hour (depending on how many muscles are being operated on).

Adjustable surgery

The ophthalmologist will discuss with you if they think an adjustable operation would be best for you. This can be useful for some people especially if there is a high risk of double vision or if you have had squint surgery before.

During the adjustable surgery, 1 suture (stitch) is made which is not completely tied off.  This allows for some adjustment when you have woken up from the main surgery.  

The adjustment takes place on the ward or in the eye clinic the morning after your operation.

If you wear glasses, you will need to bring them with you for the adjustment.

The Doctor will use anaesthetic eye drops for the adjustment. 

What happens before surgery?

· You will need to see the orthoptists on a number of occasions to take measurements of the position and movements of your eyes. This will allow the surgeon to plan how much to move the muscles.

· The orthoptist will assess the risk of double vision after the surgery.

· You will meet with the consultant to discuss the risks and benefits of the surgery so you can make an informed decision about going ahead.

· Before having a general anaesthetic you need to have a pre-operation assessment to make sure you are fit for surgery and the general anaesthetic. 

How do I prepare for surgery?

· You can eat up to 6 hours before your operation.

· You can drink clear fluids up to 2 hours before your operation.

· You will need to arrive in the morning at 11.30am, although the operation may not take place until the afternoon.

· You can usually go home the same day as your surgery.

· You will be given eye drops with instructions before you go home and a plan regarding              follow-up.

Does the surgery cure the squint?

· Most people feel some improvement in their squint after surgery, however a squint may not be completely corrected by one operation.

· In some cases, your eyes may look straighter just after the surgery.

· Some people may need another operation   during their lifetime.

The operation does not change your vision, such as a lazy eye or the need for glasses.

What are the risks of the operation? 

Squint surgery is generally a safe operation, however, as with any operation, complications can occur. These may include:

Under and Overcorrection

· Squint surgery results are not always completely predictable and therefore the squint you had before the operation may still be present (under correction).

· There may be a squint in the opposite direction after the operation (overcorrection). These problems may require more surgery.

Double vision

· You may have double vision after surgery as your brain gets used to the new position of your eyes.  This is common and often settles in a few days or weeks.  For some people, it may take months to improve.

· It is rare for double vision to be permanent after surgery.  If this does happen, more treatment will be required.

· If you had double vision before the surgery it may be different after the operation.  You will be assessed by the Orthoptist to find what will work best to reduce any double vision. 

Allergy

A mild allergic reaction to the drops that are given after the operation may cause itchy, irritated eyes and red or puffy eyelids.  This usually settles quickly once the drops are finished.

Stiches

· It is normal for the eye to feel slightly gritty before the dissolvable stitches have been absorbed.  This takes a few weeks to settle down.  

· An infection and cyst may develop around the stitches, therefore you should not swim in the first 4 weeks after the surgery. 

· A cyst normally settles when the stitches are absorbed  Occasionally further surgery is needed to remove the cyst.

Redness

· Redness in the eye which should be reducing and fade in time, may take up to 3 months to go away. 

· Occasionally the eye does not return completely to its normal colour.  This can happen if you have had more than 1 squint surgery.

Scarring

· Occasionally, visible scars may remain, especially with repeat operations.

· The scarring on the conjunctiva (a clear layer that covers the white of the eye), should reduce over a period of 3 months after surgery.

Lost or slipped muscle

· The eye movements can be affected, as the muscle can no longer pull properly.  This is caused by one of the eye muscles slipping back from its new position on the eye.  This can happen either during or shortly after the operation.

· More surgery may be required if the eye muscle slips back from its new position and it is not possible to completely correct a slipped muscle. This is why you are advised not to rub your eye in the first few weeks after surgery.

Needle penetration

· A small hole in the eye may occur and sight may be affected depending on where the hole is.  This can happen if the stitches are too deep or the white of the eye is thin. Treatment is antibiotics or laser treatment to seal the hole.

· The needle goes in too far.  This can occur if the white of your eye is thin due to squint surgery and can lead to sight loss.

· Infection or retinal detachment (inner layer of the eye), could occur due to previous surgery.  If the eye is penetrated, this can lead to loss of sight.

Anterior Segment Ischaemia (poor blood supply to the front structures of the eye).

· The blood supply to the front structures of the eye can be reduced following surgery.  These structures include the muscles that allow you to change focus and move your pupil. 

· If this occurs, the pupil may be large and vision may be blurred due to the reduction of the blood supply.  Only usually occurs in patients who have had multiple surgeries. 

Infection

Infection resulting in loss of the eye or vision. Very rare. 

Loss of vision

Loss of vision in the eye being operated on following squint surgery. 

What happens after surgery?

· Your eye (or eyes) will be swollen, red and sore.

· It is likely your vision might feel blurry too. This is normal.

· You should start using your drops the morning after your operation and use painkillers (such as paracetamol and ibuprofen) if you feel you need to. The pain usually reduces within a few days.

· The redness and discomfort may be present for up to 3 months, especially if you have had  surgery before or you had adjustable stitches.

· Remember to not rub your eyes.  Continue using your glasses as normal but avoid contact lens wear until you have seen the Doctor.

· Use cooled boiled water and a clean tissue or cotton wool to clean any stickiness from your eyes if necessary.

· Avoid water from your bath or shower from getting into your eyes for the first week. You are advised not to swim for 4 weeks.

Introduction

This leaflet provides you with information on Thyroid Eye Disease.

It is not meant to replace the discussion between you and your Doctor/Healthcare Professional but may act as a starting point for discussion.  

If after reading it you have any concerns or require further explanation, please discuss this with a member of the Healthcare Team who has been caring for you.

What is a Thyroid Eye Disease (TED)?

This is an eye condition that causes the muscles and soft tissues in and around your eye socket to swell.

It usually happens when you have a problem with your thyroid gland.

It is also called Thyroid Associated Ophthalmopathy (TAO). Thyroid Orbitopathy (TO) or Graves’ Orbitopathy or Graves’ Ophthalmopathy (GO).

TED has 2 stages:

The active stage is when there is inflammation and swelling of soft tissue.

During the active stage of TED, the treatments aim to improve symptoms and protect the eye while the condition runs its course.  This involves treating double vision and dry eye.

This usually resolves on its own and can last around 6 months to 2 years.

The inactive stage is when inflammation reduces and is replaced by scarring.  Things tend to be quite stable in this stage.

What causes Thyroid Eye Disease?

TED most commonly occurs when:

· You have an overactive thyroid.

· You have an underactive thyroid.

· The thyroid is working normally.

The most common cause of an overactive thyroid gland is ‘Graves’ disease, which is an autoimmune condition.

How can Thyroid Eye Disease affect my eyes?

The most common symptoms of TED are:

· Watery eyes.

· Gritty and sore eyes.

· Uncomfortable to look at bright light.

· Dry eyes as a result of not being able to produce tears.

· Eyes that have a bulging or staring appearance,  partly because the upper eyelid is pulled higher up in TED and is called eyelid retraction. 

· Dry eye because the front of the eye is less protected by the upper eyelid.

· Soft tissue around the eye can become inflamed which can cause puffy or red eyelids. This is usually worse in the morning.

· The muscles that move the eyes can become swollen. The swollen muscles can push the eyeball forward (this is called Proptosis). 

· The muscles are swollen and can also disrupt the movement of the eyes. This can lead to double vision which might be present in one position or constant.

· Experience of discomfort trying to move the eyes when the muscles are inflamed.

Will I need more tests?

You will need to be assessed by an Endocrinologist (a Doctor who specialises in the hormone systems of the body).

You may need blood tests and sometimes a scan of the eye sockets is required. These tests help to see how to best manage any symptoms you have.

What are the treatment options?

The Endocrinologist will advise you about treatments for your thyroid problem. 

These may include:

· Medication.

· Surgery.

· Radioactive Iodine Treatment.

Treatment for conditions caused by TED

· During the active stage of TED, treatments aim to improve symptoms and protect the eye while the condition runs its course.  Usually this involves treating double vision and dry eye.

· If compression of the optic nerve is identified then treatment is started to prevent further  compression and permanent damage to the sight. This is uncommon.

· The aim of the treatment is to reduce inflammation and swelling in the eye socket with immunosuppressant treatment, usually steroids. 

· Orbital Radiotherapy can be used for some  people to reduce swelling. 

· Orbital decompression surgery may be needed but this is rare.  It involves removing some bone from the eye socket to give swollen muscles more room and prevent pressure on the optic nerve.

Double Vision. 

Double vision occurs due to eye muscle swelling. This is assessed and treated by Orthoptists who are specialists in eye movements.

They can choose the best treatment for you depending on the severity of your TED and what stage of the condition you are in.

During the active stage when the double vision can be variable, covering or blurring one eye to resolve the double vision may be the best option. This can be done with an eye patch or clouded lens.

Some people can control their double vision better if they put their head in a different position.  You might do this without realising or your Orthoptist can give you advice about it.

During the inactive stage of TED, when things are more stable, eye muscle surgery to realign the eyes and reduce the double vision can be considered.

If your double vision becomes controlled with treatment, your Orthoptist will advise you about driving.  If you do drive with double vision, you could invalidate your insurance as it is illegal to drive with double vision that is not controlled.

Blurred Vision: 

Your optic nerve normally carries visual information from your eye to your brain.  Optic nerve compression can cause blurred vision. 

This occurs when the swelling in the eye socket causes the optic nerve to be squashed or compressed.  

If you notice changes in blurred vision, reduced colour vision and problems with peripheral vision, you should seek advice. .

Dry eye:

This can cause your eyes to feel dry and gritty and can also sometimes result in watery eyes.

Lubricating eye drops, (artificial tears) can help to make your eyes feel more comfortable and help to prevent the front of the eye from being damaged as well as reducing any watering.

Thicker gel type drops can be used to help lubricate the eyes for longer and ointments can help lubricate the eyes overnight.

If your eyelids aren’t able to close fully, your Ophthalmologist may suggest gently taping your eyelids closed at night to prevent your eyes from drying out.

Using Prisms to correct double vision

Prisms can sometimes be used to join double vision back to single. The prism bends light to move the displaced images closer together.

Long term some prisms can be incorporated into your glasses lens. 

Prisms come in different strengths. The best one for you can be assessed by the Orthoptist and it can be changed if your symptoms change.

At first you will be given a temporary prism which will be stuck onto your own glasses or a plain pair of glasses from the hospital. 

What can I do to help improve my symptoms of TED?

· If you smoke, you should stop as this can make TED much worse and treatment is less effective. Talk to your GP about accessing support to help you quit. 

· Sleep propped up on extra pillows, as the puffiness and swelling around the eyelids tends to be worse in the morning after you have been lying flat.

· Avoid windy or dusty environments where possible to help reduce dry eye.

· Take regular breaks when using screens or reading as this can help your eyes to feel comfortable.