Thyroid eye disease (TED) is an autoimmune condition where the eye muscles and eyelids become inflamed. This makes the eyes red, swollen and bulging. Read the article to know its causes, diagnosis, and treatment options.
Thyroid eye disease (TED), also called thyroid-associated orbitopathy, thyroid ophthalmopathy, or Graves’ ophthalmopathy, is a condition that mainly affects patients with hyperthyroidism, but it may occur in clinically euthyroid patients, and patients with hypothyroidism and Hashimoto’s thyroiditis as well. Thyroid eye disease occurs in patients with thyroid hormone imbalance, which commonly affects females, but it is more serious in males. The most common risk factor for thyroid hormone imbalance is smoking. Excessive smoking will lead to an imbalance in thyroid hormones. The severity will depend upon the number of cigarettes per day. The more the number of cigarettes, the more the risk. Only 40 % of disease starts simultaneously with the onset of hyperthyroidism. The other 20 to 40 % of orbitopathy begins before or after thyroid dysfunction.
It is an autoimmune disease where the patient may also be suffering from other autoimmune diseases, such as rheumatoid arthritis. The orbital fibroblast present in orbit swells due to thyroid hormone imbalance. This leads to the accumulation of water into eye muscle, which leads to bulging of eyes called proptosis.
The signs and symptoms of thyroid eye disease or thyroid orbitopathy include:
Prominent blood vessels in the eyes.
Swelling of eyelids.
Difficulty in seeing distant objects.
Difficulty in seeing a particular color.
Limited eye movement.
Retraction of the upper eyelid.
Incomplete or infrequent blinking.
Edema of the lower lid.
Conjunctival injection or redness.
Abnormal pigments over the upper eyelid.
TED is diagnosed based on the presence of characteristics, signs or symptoms. If you are exhibiting any of the following signs or symptoms, kindly consult an ophthalmologist immediately:
Presence of thyroid antibodies in the blood.
Restricted eye movement.
Abnormal color vision.
The following parameters should be checked to diagnose thyroid orbitopathy:
Proptosis or bulging of the eye.
Conjunctival chemosis (swelling of the conjunctiva).
If the doctor suspects thyroid eye disease, you might have to undergo the following investigation:
Complete slit-lamp examination.
CT scan of the orbit.
MRI of the orbit.
There are three ways to treat thyroid eye disease. They are mentioned below:
1) Non-Medical Management - In this type of management, the most important factor is smoking. Those who are having a risk of thyroid hormone imbalance should stop smoking completely without further delay. If you quit smoking, your chance to develop thyroid orbitopathy will reduce automatically by 50 %. The risk of complications will be reduced on its own.
Physical activity is a very important factor. Daily exercise is a must to reduce the risk of thyroid orbitopathy.
Keeping systemic diseases like diabetes and hypertension under control is an important factor in controlling thyroid hormone imbalance.
2) Medical Management - Antithyroid drugs will help reduce the high levels of thyroid hormone. Oral or intravenous steroids play an important role in the control of excessive thyroid hormone. Immunosuppressive drugs also have their role.
3) Radiotherapy - It is also one of the modality to treat thyroid eye disease. Radiation to the orbit will benefit those patients with active disease. Patients who are not responding to oral steroids, radiotherapy will be useful. Radiotherapy will not be helpful in patients with diabetes.
4) Surgical Procedure - There are two types of surgical procedures, which are:
Semi or partial thyroidectomy.
Patients with thyroid eye disease should be advised to sleep with the head end of the bed elevated. And at night, patients should use a topical eye lubricant to reduce discomfort. If patients have severe lid edema, they may benefit from systematic steroids. Cold compression with ice and nonsteroidal anti-inflammatory drugs (NSAIDs) may help to reduce symptoms. Passive smoking and smoking cessation will avoid the worsening of symptoms.
For severe thyroid orbitopathy, the following drug can be used:
Steroids - In case of excessive prominence of the eyeball or eyeball bulging and a drastic reduction in vision, intravenous Methylprednisolone is highly beneficial. If there is another attack of the same condition, the patient may need pulse doses of steroids every 3 to 6 weeks.
Thyroid Eye Disease and Squint:
Thyroid eye disease can lead to squinting. Squint is the deviation of the eyes. It can be in any direction. It can be an inward deviation, or it can be an outward deviation.
Management of Squint - Deviation of the eye can lead to double vision. To avoid double vision, patients can use prisms. Prisms can relieve diplopia. If double vision is not getting better with prisms, patients should undergo surgery. Surgery should be done on extraocular muscles.
Management of Eyelid Abnormalities Due to Thyroid Eye Disease:
Lid Retraction and Lagophthalmos - The inability to close eyelids while sleeping can be treated in the active phase by Botulinum toxin injection. Once the condition is stable, patients can plan surgery like levator recession or lid lengthening.
Age - The prognosis is worse in older patients.
Gender - Females are more prone.
Severity - The disease is more severe in males compared to females.
Race - The disease is more severe in Caucasian patients than in Asian patients.
Lifestyle - Smoking causes more severe disease.
Diabetes - Diabetes can cause more severe disease.
Stressful situations, emotional disturbance, pregnancy, menarche, and menopause can all affect disease severity. All the conditions mentioned above can lead to changes in the level of thyroid hormone.
If you have any issues with thyroid hormone levels or any symptoms or signs, as described in this article, it is best to consult an ophthalmologist online as early as possible to diagnose it in the early stage. Thyroid ophthalmopathy is a treatable condition if it is diagnosed in the early stage. If not treated early, the risk of complications and the severity of the disease increases. Severe disease can lead to loss of eyesight also.
Thyroid eye disease is an autoimmune disease; that is, the body\'s immune cells mistake their own body cells for foreign bodies and attack them. The immune cells cause muscles, fat, and other tissues around the eyes to enlarge in size. Its incidence is high in individuals with a high level of thyroid hormone (hyperthyroidism).
Thyroid eye disease affects the eye and surrounding tissues. The early symptoms include;
- Redness, irritation, and discomfort of eyes and eyelids.
- Dry eyes.
- Pain while moving the eyes.
- Bulging of eyes.
Thyroid eye disease has two phases - the active disease phase and the inactive phase.
Active Phase - It is characterized by inflammation, swelling, and tissue changes around the eyes. It can cause symptoms like pain, watery eyes, etc. It lasts for six months to two years.
Inactive Phase - The disease progression has stopped in this stage. But symptoms like bulging of eyes and double vision can remain.
Thyroid eye disease is a self-limiting disease. But if left untreated, it can cause complications. The treatment can involve non-medical management, medical management, radiotherapy, and surgical management.
- The non-medical management includes changes in lifestyle like cessation of smoking, exercising regularly, and keeping sugar and blood pressure levels under control.
- The medical management includes taking medication to keep thyroid hormone levels under control, oral or intravenous steroids, and immunosuppressive drugs.
- Radiotherapy is opted when non-medical, and medical management is not effective.
- Surgical management is opted when none of the above treatment modalities is effective.
The home remedies for thyroid eye disease include;
- Using lubricating eye drops.
- Avoid smoking.
- Exercising regularly to keep thyroid levels under control.
- Elevating head while laying down.
- Wear sunglasses while moving out in the sun as this can prevent eyes from getting exposed to the sun and prevent dry eyes.
Thyroid eye disease can cause damage to tissues around the eyes which can lead to scarring and tissue remodeling. These may lead to changes in the appearance of the eyes, which can be permanent.
Thyroid eye disease has two stages - active and inactive phase. If the condition is left untreated in the active phase, it may cause double vision or loss of vision. But the condition can be reversed if treatment is given at the right time.
Surgery may be required if thyroid eye disease affects the structure and function of the eyes. It is usually performed after the active stage of the disease. But in the active phase, if it affects the optic nerve and if the condition is not responding to medical treatment, then surgery can be opted.
The symptoms worsen during the first six to 12 months of the disease. Then slowly, the condition may improve. It may take upto two years for the inflammation to subside completely. But in some cases, the changes in vision and appearance of eyes cannot be reversed.
Selenium and Vitamin D supplements are generally recommended for patients with thyroid eye disease. But the role of selenium and vitamin D in thyroid eye disease is still under study.
Last reviewed at:
12 Mar 2022 - 5 min read
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