Thyroid eye disease (TED) is an autoimmune condition that affects the eye muscles and tissues around the eye. Many people with TED also have a type of hyperthyroidism called Graves’ disease.
TED usually resolves over time. Vision loss is rare, but TED can cause double vision or changes in the appearance of the eyes. For a small number of people, TED will be severe enough to require surgery, often done in multiple steps.
Symptoms of thyroid eye disease
Graves’ disease does not directly cause TED, but they both involve inflammation caused by an overactive immune system attacking healthy tissues. If you have TED, you may notice:
- red and dry eyes
- sensitivity to light
- feeling like something is in your eye
- swollen eyelids
- retracted eyelids
- bulging eyes
- eye pain, especially when moving the eyes
The two phases of thyroid eye disease
TED has an active and inactive phase. The active phase usually lasts 1–3 years. Treatment during this time is aimed at lowering inflammation.
Smoking can make TED worse, so quitting is a great first step. You can use artificial eye drops or a lubricating gel to make your eyes more comfortable. Selenium supplements may also help.
Moderate cases of TED may require prescription medications, such as steroids, to decrease swelling behind the eyes.
Your doctor may also try a newer drug called teprotumumab (Tepezza), the first treatment to be specifically approved for TED. Radiation therapy can also treat swelling and vision problems in some cases.
During the inactive phase of TED, your symptoms become stable. Treatment in this phase focuses on the function and appearance of your eyes. If TED is severe enough to requiresurgery, it’s often performed during this time. Ophthalmologists with specialized training, like oculoplastic surgeons and strabismologists, usually perform these operations over time in a stepwise order.
Orbital decompression surgery corrects eye bulging or proptosis. It can also take pressure off your optic nerve to preserve or improve your vision.
The surgery may be performed using minimally invasive techniques and small incisions. During the procedure, small segments of thin bone and sometimes fat are removed from inside your eye socket. This creates more room, allowing your eye to return to its proper place within the socket.
Orbital decompression surgery is performed to preserve eyesight and will likely not correct double vision. In some cases, it may even cause or worsen double vision. These symptoms are addressed in a different way.
The swelling and scarring caused by TED can restrict the actions of affected eye muscles, resulting in double vision. Strabismus (crossed eyes) surgery may be performed as the next step to restore proper eye alignment if double vision persists.
To fix this, your surgeon will detach and move the affected eye muscles to straighten your eyes. Once aligned, they can work together as they should, and double vision may resolve.
Sometimes TED can cause your eyelids to pull back or retract. This exposes more of your eye and may prevent your eyelids from being able to close fully. Your eyes may become dry, red, and irritated.
A surgeon can correct the positioning of your upper and lower eyelids by releasing some muscles and tissues around them. This procedure typically occurs months after strabismus surgery.
After the functional aspects of TED have been corrected, you may still notice some changes in your appearance. You may have swollen or puffy skin around your eyes. You can experience loss of elasticity of your skin in that area.
Some people undergo a final stage of surgery to address any remaining aesthetic concerns. An eyelift or facelift can remove excess tissue and smooth the skin. Lasers can help improve skin tightness.
If you have Graves’ disease and notice eye irritation, changes in how they look, or changes in your vision, talk with your doctor. Emergency surgery is rarely needed, but your doctor can monitor your symptoms and recommend treatment.