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Thyroid Eye Disease and Graves’ Disease: Understanding, Diagnosis, and Treatment Options

Graves' disease primarily affects the thyroid gland and causes it to produce too much thyroid hormone, which can lead to a range of symptoms such as weight loss, anxiety, tremors, and rapid heartbeat. Approximately 25% of people with Graves' disease develop Thyroid Eye Disease before, during or after the diagnosis of a thyroid disorder.

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Thyroid Eye Disease and Graves’ Disease: Understanding, Diagnosis, and Treatment Options Optometrist

Thyroid eye disease, also known as Graves' orbitopathy (GO) or Graves' eye disease (GED), affects the tissues around the eyes and is characterized by inflammation, swelling, and changes in the appearance of the eyes. It can cause symptoms such as bulging eyes, double vision, eye pain, and difficulty moving the eyes.

While thyroid eye disease is commonly associated with Graves' disease, it can also occur in people with other thyroid conditions or in individuals without any thyroid issues. Graves' disease is the most common cause of thyroid eye disease, but not everyone with Graves' disease will develop thyroid eye disease.

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Understanding the Signs and Symptoms of Thyroid Eye Disease

Eyelid Retraction and Thyroid Eye Disease

Eyelid retraction occurs in about 80% of people with TED. This condition causes the eyelids to be pulled back and results in a wide-eyed, startled appearance. Normally, the upper eyelid should come below the top portion of the cornea, and the white of the eye (sclera) should not be visible above the cornea. If you notice that someone's eyelids are pulled back, and you can see a significant amount of the sclera above the cornea, this may be a sign of eyelid retraction.

To test for eyelid retraction, we will ask patients to follow their finger or a pen and look up and down slowly. This helps them detect asymmetry between the two eyes, which is often present in TED. Lid lag, where one eyelid is higher than the other in down gaze, is found in about 50% of all people with eyelid retraction. Dynamic asymmetry is also checked through the Von Graefe's sign, where one eyelid falls slower than the other.

Proptosis or Bulging Eyes and Thyroid Eye Disease

Proptosis, also known as exophthalmos, is the medical term for bulging of the eyes. In people with TED, the eye muscles that surround the eyes become inflamed and swollen due to the autoimmune response that is also affecting the thyroid gland. The swollen muscles can become fibrotic, causing the eyeballs to push outward, and in some cases, the white of the eyes may become visible above the cornea. Proptosis is the most common symptom of TED and is found in about 60% of all cases.

Double Vision and Thyroid Eye Disease

Double vision, or diplopia, is a common symptom of TED. This happens because the inflamed and fibrotic eye muscles are unable to move the eyes properly, causing double vision. Typically, the inferior rectus muscles are first affected, resulting in vertical diplopia. This can be followed by the medial and superior rectus muscles and, in some cases, the lateral rectus muscles. Diplopia can be especially severe in people with TED and can lead to functional impairment.

Dry Eye and Graves Disease, Thyroid Eye Disease, and Hashimoto Disease 

Graves or thyroid eye disease can also cause dry eyes or a sensation of foreign body or sand in the eyes. One reason that can cause this is due to the eyelids not closing properly which does not allow for proper blinking which enables the tears to dry out quicker. 

Antibodies from autoimmune conditions and dry eye 

Additionally autoimmune conditions such as graves and Hashimoto's disease can cause the immune system to create antibodies that attack healthy cells such as those in and around the eye. This mechanism can cause a decrease in tear production, in the scenario where the antibodies attack the lacrimal glands that produce tears. This mechanism can also impact the ocular surface causing inflammation and poor tear quality. 

Other signs and symptoms of thyroid eye disease (TED) may include:

  • Eye pain or discomfort: Inflammation and swelling of the eye muscles and tissues can cause pain, aching, or pressure behind the eyes. This can be worsened with eye movements or when looking in certain directions.
  • Redness or swelling of the eyelids: In addition to eyelid retraction, TED may also cause the eyelids to become swollen, red, or puffy.
  • Sensitivity to light: Some people with TED may experience increased sensitivity to light or photophobia.
  • Vision changes: In addition to double vision, TED can cause other vision problems such as blurred vision, difficulty focusing, or loss of vision.
  • Color vision changes: Some people with TED may notice changes in their color vision or perceive colors differently.

TED can affect one or both eyes and can range in severity from mild to severe. The signs and symptoms may develop gradually or suddenly and can worsen over time. It is important to seek medical attention if you experience any of these symptoms, especially if they are persistent or affecting your daily activities.

Diagnosis of Eye and Vision Symptoms Resulting From Thyroid Eye Disease, Graves Disease, and Hashimoto Disease

Diagnosis of Eye and Vision Symptoms Resulting From Thyroid Eye Disease, Graves Disease, and Hashimoto Disease

The diagnosis of vision symptoms that are related to TED, Graves' disease, and Hashimoto Disease requires a comprehensive eye examination, including a thorough medical history and physical examination. We perform a thorough assessment of the ocular motility, binocular vision, and visual acuity in patients with suspected vision and ocular symptoms related to Thyroid conditions.

Graves' disease is typically diagnosed by a combination of clinical symptoms and laboratory tests. We refer patients with suspected graves' disease for further evaluation and management by an endocrinologist or primary care physician. Laboratory tests, such as thyroid function tests, thyroid-stimulating immunoglobulin (TSI) levels, and anti-thyroid peroxidase (TPO) antibodies, are useful in confirming the diagnosis of Graves' disease.

In addition to a thorough eye examination and laboratory testing, imaging studies such as computed tomography (CT) or magnetic resonance imaging (MRI) of the orbit may be necessary in cases where TED is suspected. These imaging studies can help assess the extent of the orbital involvement and identify any compressive optic neuropathy, which can be a sight-threatening complication of TED.

Diagnosis of Eye and Vision Symptoms Resulting From Thyroid Eye Disease, Graves Disease, and Hashimoto Disease

Diagnosis of Eye and Vision Symptoms Resulting From Thyroid Eye Disease, Graves Disease, and Hashimoto Disease

Treatment plans are customized to each patient, below are some general treatments that may be used for patients who are suffering from eye or vision symptoms related to thyroid related autoimmune conditions:

Steroids

Steroids can be an effective treatment for both TED and Graves' disease. They are often used in the early stages of the disease to reduce inflammation and swelling in the eye tissues. Steroids can be administered orally, topically or through injection.

Radiotherapy

Radiotherapy is a treatment option that involves the use of radiation to shrink the thyroid gland. This can be helpful in Graves' disease as an overactive thyroid gland is the root cause of this disease.

Surgery

Surgery may be required in some cases of TED and Graves' disease. This is particularly true if the condition is severe and causes significant damage to the eyes. Some of the surgeries that may be recommended include:

  • Orbital decompression surgery: This procedure involves removing some of the bones in the orbit of the eye to create more space and reduce pressure on the eye.
  • Eye muscle surgery: This surgery involves repositioning the muscles that control the movement of the eyes to improve alignment.
  • Eyelid surgery: If the eyelids are affected, surgery may be recommended to correct any abnormalities or to lift the eyelids if they are drooping.

Immunomodulatory Therapy

Immunomodulatory therapy involves using medications that can suppress the immune system. These medications can be helpful in controlling the autoimmune response that is causing TED and Graves' disease. Some common medications used in immunomodulatory therapy include:

  • Methotrexate: This medication is often used to treat cancer but can also be helpful in suppressing the immune system in autoimmune diseases like TED and Graves' disease.
  • Mycophenolate: This medication is commonly used in transplant patients to prevent organ rejection. However, it can also be used to suppress the immune system in autoimmune diseases.
  • Rituximab: This medication is an antibody that targets specific cells in the immune system that are involved in autoimmune diseases.

Eyewear and Medically Necessary Contact Lenses 

In some cases, eyewear or specialty contact lenses may be recommended to protect the eyes from further damage. This can include wearing glasses with wraparound frames or shields to protect the eyes from dust and debris. Specialty contact lenses such as scleral lenses may be recommended in cases where the patient is not producing enough tears or where the eyelids are not closing properly. 

Lifestyle changes

Lifestyle changes can also be helpful in managing TED and Graves' disease. Some lifestyle changes that may be recommended include:

  • Getting enough rest and sleep
  • Avoiding smoking and exposure to secondhand smoke
  • Managing stress through relaxation techniques such as yoga or meditation
  • Eating a healthy diet
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Why You Should See An Optometrist If You Suspect You Have Thyroid Eye Disease and Graves' Disease

Why You Should See An Optometrist If You Suspect You Have Thyroid Eye Disease and Graves' Disease

If you suspect that you may have thyroid eye disease or Graves' disease, it is essential to seek the care of an experienced optometrist. At our practice, we offer comprehensive medical eye exams, with specialized knowledge, technology, treatment options, and a patient-focused approach to care. 

Here are some of the reasons why you should choose an optometrist to help manage your eye health:

Early detection and management

Early detection and management of thyroid eye disease and Graves' disease can help prevent serious eye complications and improve outcomes. We have the experience to detect and diagnose these conditions during a comprehensive eye exam, and can develop a personalized treatment plan to address your specific symptoms and needs.

Collaborative care

We work closely with other healthcare providers, including endocrinologists and ophthalmologists, to ensure that you receive comprehensive care for your thyroid eye disease or Graves' disease. We will coordinate your care and make sure that you are getting the appropriate treatment for your condition.

Specialized knowledge and expertise

Optometrists have specialized training and experience in diagnosing and managing eye conditions such as thyroid eye disease and Graves' disease. We stay up-to-date on the latest research and treatment options to provide you with the highest level of care.

Comprehensive eye exams

A comprehensive eye exam is the first step in diagnosing thyroid eye disease and Graves' disease. During your exam, we will discuss your health history and evaluate your eye health and look for signs of these conditions, including bulging eyes, eyelid retraction, and double vision.

Patient-focused approach

At our practice, we put our patients first. We take the time to listen to your concerns, answer your questions, and develop a personalized treatment plan that meets your unique needs. We strive to provide a comfortable and welcoming environment where you feel at ease.

Don't wait to seek treatment if you suspect that you have thyroid eye disease or Graves' disease.

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Common Questions

Thyroid eye disease (TED) is an autoimmune condition that affects the muscles and tissues around the eyes, causing swelling, inflammation, and protrusion of the eyes. While TED is commonly associated with Graves disease, they are not the same condition. Graves disease is an autoimmune disorder that primarily affects the thyroid gland, causing hyperthyroidism (an overactive thyroid). However, Graves disease and TED often occur together and are commonly seen in patients with autoimmune thyroid diseases.
No, not everyone with Graves disease will develop thyroid eye disease. However, TED is more common in patients with Graves disease, and about 25% of people with Graves disease may develop TED.
Hashimoto’s thyroiditis (hypothyroidism) can also impact the eye, although the prevalence of thyroid eye disease is much lower in those with Hashimoto than those with Graves Disease. The most common symptom of hashimoto disease is dry eye. There are numerous treatment options that may be recommended such as medications, steroids, scleral lenses, punctal plugs, and amniotic membranes.
While removing the thyroid gland (thyroidectomy) can help to control hyperthyroidism caused by Graves disease, it does not cure Graves eye disease. TED is a separate condition that affects the eye muscles and tissues and requires specialized treatment.
Graves disease affects the eyes by causing inflammation and swelling in the eye muscles and tissues, leading to eye protrusion (exophthalmos), eye discomfort, double vision, dry eyes, and vision loss in severe cases. The immune system mistakenly attacks the eye muscles and surrounding tissues, causing them to become inflamed, leading to eye-related symptoms.
The treatment of Graves eye disease depends on the severity of the condition. Mild cases can be managed with lubricating eye drops and ointments, while more severe cases may require oral or intravenous steroids, immunosuppressants, or surgery to correct vision problems and reduce eye bulging.
Yes, Graves eye disease is treatable, and the treatment depends on the severity of the condition. Early diagnosis and treatment are crucial in managing the symptoms and preventing complications such as vision loss.
Graves disease is a chronic condition, and there is currently no cure. However, it can be managed with medications, radioactive iodine therapy, or surgery to remove the thyroid gland.
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Take Action Against Thyroid Eye Disease and Graves' Disease - Schedule a Comprehensive Eye Exam Today!

Thyroid eye disease is an autoimmune disorder that affects the tissues around the eyes, causing inflammation, swelling, and changes in appearance. Symptoms include bulging eyes, double vision, eye pain, difficulty moving the eyes, eyelid retraction, proptosis, and dry or gritty sensations in the eyes. Early diagnosis and treatment, including comprehensive eye exams and specialized care, can help prevent serious eye complications and improve outcomes.

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