Thyroid Eye Disease: Symptoms, Causes, and Treatment Options
- David B. Sabin
- 3 days ago
- 5 min read
Thyroid eye disease, often called TED, Graves’ eye disease, or Graves’ orbitopathy, is an autoimmune condition where inflammation affects the muscles, fat, and soft tissues around the eyes. It is most commonly associated with Graves’ disease and hyperthyroidism, but it can also occur in people with normal or low thyroid levels.
For some patients, thyroid eye disease causes mild dryness and irritation. For others, it can lead to eye bulging, double vision, eyelid changes, exposure problems, or rarely, vision-threatening pressure on the optic nerve.
What Causes Thyroid Eye Disease?
Thyroid eye disease happens when the immune system mistakenly attacks tissues around the eyes. This causes inflammation and swelling in the orbit, which is the bony space around the eye.
As the tissues behind the eye swell, the eye may be pushed forward. The eye muscles may also become enlarged or stiff, which can lead to double vision or difficulty moving the eyes normally.
TED is often linked with thyroid imbalance, but the eye disease and the thyroid blood levels do not always move together. A patient’s thyroid blood work may improve while the eye disease remains active.
Common Symptoms of Thyroid Eye Disease
Symptoms can range from mild to severe. Common signs include:
Dry, gritty, burning, or irritated eyes
Redness or swelling around the eyes
Watery eyes
Light sensitivity
Eyelid retraction, where the eyes look more open or “staring”
Eye bulging, also called proptosis
Pressure or aching behind the eyes
Double vision
Difficulty closing the eyes completely
Blurry vision
Reduced vision or washed-out color vision in severe cases
One important point: thyroid eye disease can be asymmetric. One eye may look or feel worse than the other.
Why Thyroid Eye Disease Needs an Eye Exam
TED is not just a cosmetic concern. When the eyes protrude or the eyelids do not close fully, the front surface of the eye can dry out and become damaged. In more advanced cases, swelling behind the eye can place pressure on the optic nerve, which can threaten vision.
An eye doctor may check:
Vision and color vision
Eye pressure
Eyelid position
Eye movement
Double vision pattern
Amount of eye bulging
Corneal exposure or dryness
Optic nerve appearance
Visual field testing if nerve compression is suspected
The Two Phases of Thyroid Eye Disease
TED is often described in two phases.
1. Active Inflammatory Phase
This is when swelling, redness, discomfort, eyelid changes, eye bulging, or double vision may be changing or worsening. This phase is usually when medical treatments are most helpful.
2. Stable or Inactive Phase
In this phase, the inflammation has quieted down, but structural changes may remain. A patient may still have bulging eyes, eyelid retraction, or double vision. Surgery is usually considered once the disease is stable, unless there is an urgent vision-threatening problem.
Risk Factors That Can Make TED Worse
Smoking is one of the biggest modifiable risk factors for thyroid eye disease. Patients with TED are strongly encouraged to stop smoking and avoid secondhand smoke exposure.
Keeping thyroid levels stable is also important. Thyroid dysfunction can worsen or prolong eye disease, so care often involves both an eye doctor and an endocrinologist.
Treatment for Mild Thyroid Eye Disease
Mild TED may be managed with supportive treatment and close monitoring.
Artificial Tears and Lubrication
Preservative-free artificial tears can help with dryness, burning, and irritation. Lubricating ointment or gel may be recommended at night, especially if the eyes do not close completely during sleep.
Cool Compresses
Cool compresses may help reduce swelling and discomfort around the eyes.
Sunglasses
Sunglasses can help with light sensitivity and wind exposure. Wraparound sunglasses may be especially helpful outdoors.
Sleep Position
Sleeping with the head slightly elevated may reduce morning eyelid swelling.
Selenium
Some guidelines support a 6-month course of selenium for mild Graves’ orbitopathy, especially in regions where selenium deficiency is more common. This should be discussed with a doctor before starting, especially for patients taking other supplements or medications.
Treatment for Moderate to Severe Thyroid Eye Disease
More active or severe TED may require medication, infusion therapy, or referral to an oculoplastic specialist, neuro-ophthalmologist, endocrinologist, or orbital disease specialist.
Steroids
Corticosteroids can reduce inflammation and swelling during active disease. European guidelines have recommended intravenous methylprednisolone as a major treatment option for active moderate-to-severe Graves’ orbitopathy, often in weekly infusions depending on severity and risk factors.
Steroids may improve inflammation, redness, swelling, and discomfort, but they may not fully reverse long-standing eye bulging or double vision.
Teprotumumab / Tepezza
Teprotumumab, also known by the brand name Tepezza, is a biologic medication used to treat thyroid eye disease. It targets the IGF-1 receptor pathway, which plays a role in the inflammation and tissue expansion seen in TED. It has been shown to reduce proptosis, inflammation, and diplopia in many patients.
This treatment is usually given as a series of IV infusions. It is generally considered for patients with moderate-to-severe disease, but the decision depends on disease activity, severity, medical history, insurance criteria, and specialist evaluation.
Important possible side effects include muscle cramps, gastrointestinal symptoms, worsening inflammatory bowel disease, blood sugar changes, hair loss, and hearing-related symptoms. Patients considering this treatment should have a detailed risk-benefit discussion with their doctor.
Other Immune-Modulating Treatments
Some patients may be treated with other medications that suppress or modify the immune response. EUGOGO guidelines discuss options such as IV steroids, mycophenolate, and second-line treatments depending on severity and response.
Surgical Treatment for Thyroid Eye Disease
Surgery is often considered after the disease becomes stable, especially when the patient still has eye bulging, double vision, eyelid retraction, or exposure problems.
Orbital Decompression Surgery
Orbital decompression creates more space in the orbit so the eye can sit farther back. This may be used for significant eye bulging or, urgently, if the optic nerve is compressed.
Eye Muscle Surgery
If thyroid eye disease causes persistent double vision, eye muscle surgery may help realign the eyes once the disease is stable.
Eyelid Surgery
Eyelid surgery can improve eyelid retraction, exposure, comfort, and appearance.
When Thyroid Eye Disease Is an Emergency
Patients with TED should seek urgent eye care if they develop:
Sudden decrease in vision
New or worsening double vision
Eye pain with vision changes
Colors looking faded or washed out
Severe inability to close the eyes
A white spot, ulcer, or severe pain on the cornea
Rapidly worsening eye bulging or swelling
Sight-threatening thyroid eye disease can occur when swelling compresses the optic nerve or when exposure severely damages the cornea. Guidelines recommend urgent treatment for sight-threatening disease, often with high-dose IV steroids and specialist care.
How an Optometrist Helps Manage Thyroid Eye Disease
An optometrist can play an important role in detecting and monitoring TED. During an eye exam, your doctor can check for dry eye, corneal exposure, eye pressure changes, optic nerve issues, double vision, and visual field changes.
For many patients, the best care involves a team approach with:
Optometrist
Endocrinologist
Primary care doctor
Oculoplastic surgeon
Neuro-ophthalmologist, when needed
Final Thoughts
Thyroid eye disease can be mild, but it should not be ignored. Early diagnosis and monitoring can help protect vision, reduce discomfort, and identify patients who may benefit from advanced treatment.
If your eyes look more open than usual, feel dry and irritated, appear to be bulging, or you are noticing double vision, schedule a comprehensive eye exam. The earlier thyroid eye disease is recognized, the better the chance of managing inflammation before permanent changes occur.
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