Thyroid Eye Disease

WHAT IS THYROID EYE DISEASE?

Thyroid Eye Disease (TED) is when the orbital tissues, including the eyelids, eye muscles, tear glands, and fatty tissues surrounding the eye become inflamed. TED (also called Graves’ Ophthalmopathy) is an autoimmune reaction – inflammatory cells in the body attack the orbital tissues causing swelling and stiffness of the tissues.1 This can push the eye forward, limit the ability of the eye muscles to move the eye or even compress the optic nerve, leading to eye redness and bulging, double vision or even loss of vision.2 In many cases, the inflammatory cells can attack the thyroid gland as well leading to hyperthyroidism.

WHO IS AT RISK FOR THYROID EYE DISEASE?

Patients with hyperthyroidism (high thyroid hormone levels) or hypothyroidism (low thyroid hormone levels) are at risk for TED, although TED can be found in individuals with normal thyroid hormone levels.3 Female sex, older age, and smoking are the most widely established risk factors for TED.4

WHAT ARE THE SIGNS AND SYMPTOMS OF THYROID EYE DISEASE?

The most common presenting sign of TED is lid lag – when the upper lid remains in abnormally high position when looking down (occurring in 90% of patients with TED), followed by eyes bulging forward (60%,) and restriction of eye movements (40%).Eyelid retraction, when the upper and lower lids are pushed back making the whites of the eyes more visible. The eyes may become dry if the lids are not closing adequately leading to foreign body sensation in the eyes, eye redness, blurry vision, or eye pain.  If space behind the eye become too tight, the optic nerve, which is the connection between the eye and the brain, can be compressed leading to vision loss and even blindness.  Double vision has been reported in over 50% of patients with TED and up to 26% report low visual acuity.6

WHAT CAN BE DONE TO HELP PREVENT OR LIMIT THYROID EYE DISEASE?

Avoiding smoking and secondhand smoke and keeping thyroid levels under control are the best ways to prevent and limit the severity of TED.7 

WHAT TREATMENT IS AVAILABE FOR THYROID EYE DISEASE?

Treatment for mild disease is supportive including keeping the eyes well lubricated with over-the-counter lubricant drops.  Teprotumumab became the first FDA approved treatment for TED in 2020. In studies, teprotumumab was proven to reduce eye bulging and relieve other symptoms of TED including eye pain, double vision, and eye redness.8 In some severe cases, steroids, radiation, or other medications can be used to relieve swelling.

If double vision or optic nerve compression cannot be controlled with medication, sometimes surgery is necessary to relieve compression behind the eyes or to restore single vision.  Surgery to adjust eyelid position is also needed in some cases.  Occasionally, radiation can be used to treat active inflammation as well.

For more information on TED you can visit these websites:

Thyroid Eye Disease: A Summary of Information for Patients

https://webeye.ophth.uiowa.edu/eyeforum/patients/thyroid-eye-disease.htm

Thyroid Eye Disease: An Introductory Tutorial and Overview of Disease

https://eyerounds.org/tutorials/thyroid-eye-disease/Thyroid-Eye-Disease.pdf

Thyroid Eye Disease Charitable Trust

http://tedct.org.uk/thyroid-eye-disease

Graves’ Disease & Thyroid Foundation

https://www.gdatf.org/about/about-graves-disease/

American Academy of Ophthalmology

https://www.aao.org/eye-health/diseases/what-is-graves-disease

  1. Eckstein AK, Plicht M, Lax H, et al. Thyrotropin receptor autoantibodies are independent risk factors for Graves’ ophthalmopathy and help to predict severity and outcome of the disease. J Clin Endocrinol Metab 2006;91(9):3464-3470. 
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