Facts About Thyroid Eye Disease

Also known as Graves’ ophthalmopathy, thyroid eye disease affects as many as 1 in 3 people who have Graves’ disease. Eye symptoms can occur anytime, but they typically begin within the first year of a Graves’ disease diagnosis.

Here’s what to know about this eye condition.

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What Is Thyroid Eye Disease?

Thyroid eye disease is caused by inflammation in the tissues surrounding the eyes, usually in people who have Graves’ disease.

Graves’ disease occurs when the body mounts an attack against itself. Antibodies begin attacking the thyroid — the butterfly-shaped gland at the base of the neck — and sometimes the cells behind the eyes, which can eventually lead to thyroid eye disease.

As antibodies attack cells on the eyes called orbital fibroblasts, they release inflammatory substances called cytokines, explains Andrea Kossler, MD, an associate professor of ophthalmology at Stanford University School of Medicine in Palo Alto, California, and a thyroid eye disease specialist. “This causes pain, swelling, and redness in the eyes,” she says.

Experts believe these orbital fibroblasts essentially grow into fat or muscle cells. As a result, the body produces additional fat behind and around the eye, which pushes the eye forward, causing eye bulging. The muscles that control eye movement can also get larger, causing double vision, Dr. Kossler explains.

As thyroid eye disease advances, this process can eventually compress the optic nerve, threatening vision, so it’s important to have the condition diagnosed and treated as soon as possible.

Common Symptoms of Thyroid Eye Disease

Because thyroid eye disease affects the muscles and tissues around the eyes, it can cause changes in the appearance of the eyes, as well as pain and discomfort. Symptoms can include:

Bags under the eyes
Blurred or double vision
Bulging/staring eyes
Decreased eye motility (movement)
Dry eyes
Gritty feeling in the eyes
Low tolerance to bright lights
Pain
Redness
Swelling
Tearing

How Is Thyroid Eye Disease Diagnosed and Monitored?

Thyroid eye disease is often diagnosed after Graves’ disease. Because Graves’ is a lifelong condition, you’ll need to see your primary care physician for regular exams and lab work to check your thyroid function and make sure your treatment plan is working.

If you’ve been experiencing symptoms of hyperthyroidism — diarrhea, heat intolerance, irritability, rapid heartbeat, trouble sleeping, or unintentional weight loss — that would also prompt your doctor to order thyroid tests.

If you are diagnosed with Graves’ disease, you should have a baseline eye exam done with an ophthalmologist, who can monitor your eyes for any developing problems.

Less often, people will develop eye problems before they develop thyroid abnormalities, says Kossler. The eye disease may even appear when the thyroid is not overactive, making it even more complicated.

“Thyroid eye disease is commonly misdiagnosed,” says Kossler. “It can take moderate or severe disease before it’s correctly diagnosed.” If you notice common signs and symptoms, such as eye pain, redness, swelling, or a change in the appearance of your eyes, she recommends seeing an ophthalmologist to get lab work done to rule out thyroid eye disease.

When it comes to diagnosing the condition, an ophthalmologist can review your symptoms and conduct a focused physical exam. They may also suggest a computed tomography (CT) scan to examine your eyes, including the optic nerve and muscles.

How Is Thyroid Eye Disease Treated?

There are several treatment options for thyroid eye disease. “If you have thyroid eye disease, it’s extremely important to see your endocrinologist to get your thyroid under control,” says Kossler. While this does not treat thyroid eye disease itself, she says, it’s an important first step.

Selenium plays a key role in thyroid function. Research has found selenium supplements to be beneficial in the management of mild eye disease. Taking this antioxidant supplement may help decrease the progression of thyroid eye disease in people who have mild-to-moderate forms of the condition, says Kossler. Your doctor may also recommend eating Brazil nuts, which are naturally rich in the mineral.
Artificial tears can help relieve dry eye and redness.
Dark sunglasses can ease the effects of light sensitivity.
Fresnel prisms can help address double vision.
Steroids can help decrease inflammation, puffiness, and swelling.
Radiation can decrease inflammation of the tissue in the eye socket, but its effectiveness in thyroid eye disease remains uncertain. One review found that radiation can improve some symptoms of thyroid eye disease, but more research is needed.
Surgery can correct eye and eyelid position.
An intravenous infusion can help prevent inflammation and decrease proptosis (eye bulging).

The treatment that’s right for you will depend on whether you have a mild, moderate, or severe case of the disease, says Kossler. Your doctor will also take your personal health history into consideration.

Thyroid eye disease sometimes subsides on its own, without treatment, she says, so doctors will take a watch-and-wait approach with some people. If the symptoms of thyroid eye disease are interfering with your quality of life, your doctor may recommend using artificial tears.

But if you’re experiencing eye bulging or vision changes, which are characteristics of a more advanced stage of the disease, you may want to consider surgery or an intravenous infusion of teprotumumab, a systemic treatment for thyroid eye disease.

Potential Complications

Thyroid eye disease is often difficult to diagnose and can be misdiagnosed as hay fever or allergies.

But if you have been diagnosed with Graves’ disease and begin to have eye symptoms, see your doctor immediately to reduce your risk of complications, which can include:

Exposure Keratopathy Because thyroid eye disease displaces the eyeball and overexposes the cornea, it’s one of the main causes of exposure keratopathy, a condition in which the cornea is damaged from prolonged exposure to the outside environment.

Dysthyroid Optic Neuropathy In 4 to 10 percent of people with thyroid eye disease, dysthyroid optic neuropathy can occur. It can diminish your vision, alter your color perception, and more. This condition can be reversible if treated. But left untreated, it can lead to vision loss.

Diabetes This is not a direct complication of thyroid eye disease but a condition that can occur in conjunction with it. According to a review, people with diabetes have a greater chance of developing thyroid eye disease — and with greater severity. Conversely, treatment for thyroid eye disease can affect glycemic control, exacerbating diabetes symptoms or putting people with thyroid eye disease at risk for diabetes.

Research and Advances

Teprotumumab is a major advancement in the treatment of thyroid eye disease. It is a monoclonal antibody that has been shown to improve double vision, reduce proptosis, and reverse the restructuring of orbital tissue caused by thyroid eye disease.

Other therapies being researched are showing promise and may be available in the next few years, according to a study. These treatments include:

RVT-1401, a monoclonal antibody that may reduce proptosis and slow the overproduction of thyroid hormones
Statins, which studies have shown can improve double vision and eyelid opening
Belimumab, a monoclonal antibody that can improve overall thyroid eye disease symptoms
Local injection of corticosteroid into the eye socket to reduce inflammation and pain
Anti–vascular endothelial growth factor, which decreases the blood vessel density associated with thyroid eye disease
VRDN-001, a monoclonal antibody similar to teprotumumab, but with more convenient dosing

Discuss the options with your ophthalmologist and/or endocrinologist to find the best treatment for you. They can also go over the latest medications approved for treatment. According to Ilya Leyngold, MD, an oculofacial surgeon in Meridien, Idaho, there is currently a lot of ongoing research dedicated to improving treatment options for people with thyroid eye disease. “The goal in the future is centered on minimizing the costs and improving how the drugs are administered,” says Dr. Leyngold.

The Takeaway

Thyroid eye disease is a chronic condition that requires monitoring with regular checkups. The disorder can be managed with treatments to help reduce and control symptoms. And research will continue to expand ways to help people preserve their vision and reduce their risk of complications.

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