What Is Thyroid Eye Disease (TED) or Graves’ Orbitopathy?

Graves’ disease is an autoimmune disorder that primarily affects the thyroid gland. Approximately 27 percent of patients with Graves’ disease in North America will develop an eye disease that is known as Thyroid Eye Disease or Graves’ orbitopathy. Symptoms can include double vision, also called diplopia. Five percent of people with Graves’ orbitopathy will need eye surgery.

Graves' disease diagram

Graves' Disease Eye Symptoms

When Graves' disease affects your eye, the fat and muscles around it become larger. This can cause your eye to bulge outwards, preventing the eyelids from closing completely. Also, because the bony eye socket around your eye (orbit) has not changed in size, your enlarged eye muscles may not move properly. This can cause double vision.  

If your eyelids don’t close completely, you can experience any of the following: 

  • Dry or watery eyes
  • Scrapes on the surface of the eye
  • Change in how your eyes appear, such as staring or bulging
  • Bags under your eyes
  • Blurred or double vision
  • Difficulty moving your eyes
  • Gritty feeling in your eyes
  • Pain in or behind your eyes, especially when you look up, down, or sideways
  • Redness of your lids and eyes
  • Swelling or fullness in one or both eyelids (upper)
  • Sensitivity to bright lights

Because there is less space in your eye socket (intraorbital), you may feel greater pressure on your eye nerve. This pressure on the nerve can cause your eyesight to get worse.

Thyroid Eye Disease Surgery Treatment

We can treat mild cases of Graves’ orbitopathy with medications, such as lubricating eye drops and steroids. Other options include surgery. The UTED team at the University of Utah will work with you to determine if you need any of these surgeries.

Each of these surgeries addresses different aspects of Graves’ orbitopathy.

Decompression Surgery Options

Decompression surgery removes bone and soft tissues from behind the eye to create more space.

Patients with these significant problems may want to consider endoscopic orbital decompression:

  • Eye irritation
  • Bulging or staring eyes/cosmetic deformity
  • Double vision
  • Reduced vision.

Other surgery options:

Eye Muscle Surgery

This surgery corrects severe double vision. 

Eyelid Surgery

Eyelid surgery can improve both how your eyelids look and how they function.

Thyroid Eye Disease Medical Treatment

The U.S. Food and Drug Administration (FDA) recently approved a medication called Tepezza (teprotumumab) to treat adults with thyroid eye disease. The move represents the first drug approved for the treatment of thyroid eye disease.

How it Works: 

  • Tepezza is a specialized monoclonal antibody that specifically targets the insulin-like growth factor-1 receptor and thyroid-stimulating hormone receptor to prevent orbital fibroblasts (cells found in connective tissues) from causing inflammation and swelling in the eye socket.

Benefits:

  • 8 out of 10 people had less eye bulging in as few as six weeks.
  • 7 out of 10 had improvement in double vision while 5-10 people had a complete resolution of double vision.
  • 2 out of 3 people had resolution of pain, redness, and swelling as soon as six weeks, and improvement continued throughout their treatment with Tepezza.
  • Some side effects of Tepezza can be muscle spasms, nausea, alopecia, diarrhea, fatigue, hyperglycemia, hearing impairment, dysgeusia, headache, and dry skin.

We can treat mild cases of Graves’ orbitopathy with medications, such as lubricating eye drops and steroids.

There also are other medical treatments that can be tried to help improve the quality of life and symptoms. 

  • Get prism glasses to help you with double vision. It may be possible to optically realign eyes using prisms either applied to glasses or ground into the lens. However, when prisms do not work, eye surgery may be necessary.
  • Try high-dose steroid medications or radiation, or both, to improve inflammation and double vision.
  • Attend support groups or take counseling to address the appearance of your eyes.
  • The optic nerve can also be affected, resulting in vision loss. When it occurs, treatment is usually high-dose steroids (prednisone). For those patients who will not tolerate steroids, radiation therapy may be of benefit. If the muscles cannot be made small enough to relieve the compression of the optic nerve, then the orbit can be made larger with endoscopic orbital decompression Since the optic nerve is usually compressed at the very back of the orbit, removing the orbit's posterior medial wall is most critical. This may be done directly (through the soft tissues or skin around the eye), through the sinus under the eye, or through the nose.

Patients can also control the severity of TED symptoms by trying these things: 

  • Quit smoking. TED treatments are less effective for current smokers.
  • Take selenium supplements, which are available over the counter.
  • Take hormone therapy to keep your thyroid hormones at normal levels. Test your blood regularly and follow your doctor’s instructions, including taking prescribed medications.

Frequently Asked Questions

How Long Does Thyroid Eye Disease Last?

Thyroid eye disease (TED) is an autoimmune disease that needs to be diagnosed with a physical exam and laboratory tests. There is currently no cure for TED, but you will receive specialized therapies once you are diagnosed with TED.   

Can Thyroid Eye Disease Go Back to Normal?

With the appropriate treatment plan, your eyes can return to normal. Each treatment plan is unique and developed for you.

Can Thyroid Eye Disease Cause Blindness? 

Yes, but fortunately, this is a rare complication. It is important to be seen and have an individualized treatment plan developed by your physicians in the UTED program. 

Who Treats Thyroid Eye Disease?

At the University of Utah, we have a specialized group of physicians in the UTED program involved in diagnosing, treating, and managing your Graves’ eye disease. Endocrinologists, ophthalmologists (orbit surgeons), and otolaryngologists (endoscopic sinus surgeons) comprise the UTED team. 

Does diet affect Thyroid Eye Disease?

People with Graves’ disease may want to stay away from eating foods with large amounts of iodine—such as kelp, dulse, or other kinds of seaweed—that may cause or worsen hyperthyroidism. Taking iodine supplements can have the same effect. Avoid biotin supplements as they can interfere with your thyroid blood tests.

Do eye drops help for Thyroid Eye Disease?

Eye drops can help lubricate and relieve dry, irritated eyes. We suggest avoiding eye drops that contain redness removers or preservatives. If orbital swelling is extensive, the lid may not be able to close fully. Using lubricating eye gels can help improve moisture.

Thyroid Eye Disease Team