Rare thyroid eye disease can occur alongside hyperthyroidism

Q: 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?

A: 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 4 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.

Q: Your column regarding an older man's doctor who denied him a PSA test struck a nerve. He was just told no without an explanation. As I get older, I find that my doctors don't listen to me. Can you please talk about ageism in medical care? Are there strategies for patients to overcome it?

A: The term "ageism" refers to the various stereotypes, assumptions and preconceptions that are connected to someone's older age, which result in their being treated differently.

Unfortunately, as with many other areas of life, ageism is present in medical care. Age bias shows up in the way that health care providers talk to their patients, the degree to which they listen, the range of diagnostic tests they offer and the scope of treatments they are willing to make available.

A number of recent studies have focused on the growing prevalence of ageism in health care. Not surprisingly, they have found it leads not only to a lower quality of life for older patients, but can also result in missed or delayed diagnoses, more emergency room visits, more frequent hospitalizations and a shorter life span.

A common form of ageism is "elderspeak." Nurses, doctors and support staff may address older patients as "honey," "dear" or "young lady"; limit the vocabulary they use and dumb down explanations; or even use a singsong voice, as when soothing an infant. This type of communication is not only embarrassing, but it is patronizing and can be isolating.

Patients with poor hearing or eyesight say they are often treated as cognitively impaired. Some older adults find that treatable conditions - such as chronic pain, arthritis and neuropathy - are dismissed as a feature of older age.

While it is true that guidelines for screening tests and therapies change as we grow older, the intent is not to limit care. Rather, it reflects the shift in risks and benefits that can take place in older age. In our own practices, we do embrace a more conservative approach with older patients in diagnostics and management.

For instance, our approach to a 40-year-old with knee arthritis differs from that of a 90-year-old. Our goal is not to over-diagnose or over-treat. That said, we strongly believe that shared decision-making is even more paramount with older adults.

We will explain a diagnosis in detail, and in outlining treatment options, we always ask our patient, what matters to you? Is it symptom management, quality of life, fewer interventions, longevity? The answers become the starting point of our treatment.

Some older adults may benefit from a geriatrician as a primary care physician. Geriatricians have advanced training in health issues that affect older adults, and they often have more time for appointments.

If you are otherwise happy with the care you are receiving, you may have to firmly but politely alert a health care provider to their ageist behavior. A matter-of-fact statement like, "I am older, but I am mentally sharp. I'm interested in all of my medical options and I need our appointments to reflect that," can be quite effective.

• Dr. Eve Glazier is an internist and associate professor of medicine at UCLA Health. Dr. Elizabeth Ko is an internist and assistant professor of medicine at UCLA Health. Send your questions to askthedoctors@mednet.ucla.edu.