Hyaluronic Acid Gels for Upper Lid Retraction in Active Stage Thyroid Eye Disease

Thyroid eye disease (TED) is an autoimmune disease that affects the eye area. The disease
presents with a variety of physical findings, including bulging of the eyes (proptosis),
upper and lower eyelid retraction, and swelling/inflammation of the eye itself.

The disease passes through two phases: active and inactive. The active phase lasts between 18
and 24 months. During this phase, TED signs and symptoms generally worsen and then often
improve. The inactive phase follows, during which the signs and symptoms of TED cease to
improve and usually stabilize.

Lid retraction is a cardinal sign of TED. In addition to potentially causing cornea damage
due to improper lid closure, lid retraction is also very troublesome for patients due to its
cosmetic appearance. The precise pathophysiology of lid retraction is poorly understood, but
a leading hypothesis is that it occurs due to scarring and fibrosis in the muscles that lift
the eyelid.

Currently, the definitive treatment for lid retraction is surgery, which can be used to
lengthen the lid itself or remove inflamed tissue from behind the eye, thus causing the eye
to bulge less. In cases when patients first present to their physician with corneal
ulceration or compression of the optic nerve, surgery may be performed immediately. However,
in most instances, surgical procedures are delayed until the active stage of the disease has
passed. Thus, most patients must endure the cosmetic and irritant symptoms of TED for up to
two years.

Hyaluronic Acid Gels (HAG) have been FDA approved for the treatment of facial rhytids
(wrinkles). They are injected under the skin and work by increasing volume. Recently, some
smaller retrospective research studies have shown that HAG is also effective in correcting
upper and lower eyelid retraction in TED. Hence, HAG may be for patients with active stage
TED. It is also thought that if employed early in active phase disease, HAG may also help to
decrease the severity of associated symptoms and reduce the need for surgery.

The purpose of the current investigation is to define the clinical utility of HAG correction
of upper eyelid in active TED in terms of anatomic (lid position), quantitative (corneal dry
eye signs) and qualitative effects (symptom severity and thyroid related quality of life).