Thyroid Eye Disease (TED) &
Eye Bulging Problems

About Thyroid Eye Disease (TED)

Approximately 70% will at some point develop problems related to their eyes. There are many names given to the eye syndrome occurring in thyroid abnormalities. The most common name is Grave’s disease, named after Dr. Graves, who first described the eye problems in 1875. The eye changes associated with thyroid disease are seen in all types of thyroid disorders. Most commonly, they develop in patients who are or were hyperthyroid (overactive thyroid). Eye problems can occur in patients who have an underactive thyroid or even normal thyroid. The eye disease is not necessarily related to the control of your thyroid levels. Most people will develop thyroid eye problems within 1 year of their thyroid diagnosis. While most eye problems related to thyroid disease are mild, some can be quite disfiguring and traumatic. There is a great deal that can be done to evaluate and treat patients with thyroid related eye problems.

What Causes Thyroid Eye Disease?

Much research has been done in the abnormalities associated with thyroid disorders. It is known that the immune system reacts to the patient’s thyroid gland cells to cause thyroid abnormalities. This same immune system reaction is also noted in the eye muscles and orbital soft tissue. Inflammatory white blood cells called lymphocytes and fibroblasts cause changes in the eye muscles and orbital fat, which leads to the accumulation of fluid and inflammation. This process can lead to the development of eye symptoms of irritation with increased volume of the eye muscles and orbital fat, eyelid retraction, caused by abnormalities to the eyelid muscles and double vision caused by abnormality to the muscle function. It is important to point out that the eye problems that are related to thyroid problems can act independently of the thyroid gland. For instance, a well treated thyroid patient who is well controlled and without thyroid related problems, may continue to have thyroid eye problems and visa versa. Your thyroid eye specialist will be in close contact with your doctor, to manage this disease from both the thyroid gland and the eye related aspect.

Smoking and Thyroid Eye Disease

While we do not have all the answers to the thyroid eye disease puzzle, we do have good evidence that patients with thyroid eye disease will exacerbate their problems if they smoke. Furthermore, patients who stop smoking, often benefit with an improvement in their thyroid eye disease. Smoking cessation will also improve the healing process should you require surgery.

Double Vision

The immune system’s attack on the eye muscles and their subsequent accumulation of fluid make eye muscle movement problems in thyroid eye disease common. Patients will often complain of double vision and can be noted to have asymmetric or abnormal movement of their eyes. It is important for the patient to understand that this problem requires some stabilization and that correction is possible. Conservative management includes the incorporation of prisms into your eyeglasses. Eye muscle surgery may be performed to realign the eyes as well.

Eye Protrusion

The same process that causes abnormalities to the eye muscles and increases the fluid in the eye muscles and orbital fat will cause a forward displacement of the eyeball, simply because of the increased volume in the bony eye socket. As the eye protrudes forward, it can cause several problems. Cosmetic deformity along with the upper eyelid retraction can give the characteristic stare. Excessive protrusion may make eyelid closure difficult and therefore, eyeball and corneal protection may be compromised. Correction of the upper eyelid retraction and removal of prolapsing orbital fat pockets of the eyelids may help to camouflage the abnormal appearance. When severe, orbital decompression can be utilized to expand the volume of the eye socket and allow the eyeball to achieve a more normal position. Our specialists will discuss these considerations with you.

Vision Loss

The most dreaded complication associated with thyroid eye disease is vision loss. This is related to the increase in volume in the eye socket. The eye socket can be thought of as a “cone” where the ape has all of the eye muscles and nerve fibers crowded in a very tight space. Any increase in volume of the eye muscles and orbital fat can compress the optic nerve in this small space. This may not be noticed at first by the patient, but may be uncovered by color vision testing and formal peripheral visual field testing. It can also be evidenced by abnormal response to pupil examination. When severe, it can even be noticed by the patient as a loss of central vision. This serious problem is often referred to as compressive optic neuropathy. Compressive optic neuropathy is usually treated immediately with oral steroids and planning is made for orbital decompression surgery. Occasionally, radiation treatments can aid in treating this problem. Although this is an uncommon problem, it is imperative that all patients with thyroid eye disease be evaluated on an ongoing basis.

Cosmetic Considerations

People with thyroid eye disease often have a characteristic stare related to eyelid retraction and the protrusion of the eye that occurs. Additionally, they may show significant orbital fat prolapse and fluid accumulation, which can account for significant bags around the eyelids. Every patient should understand that while thyroid eye disease can be very frustrating, it can also be treated. With patience and perseverance, together we can accomplish a lot to improve your comfort and appearance.


TEPEZZA® is a medication that is given intravenously and provides relief for many thyroid eye problems by acting at the source of the problems rather than the symptoms alone. In fact TEPEZZA® can reduce eye bulging in 80% of thyroid eye disease sufferers. Besides reducing eye bulging, TEPEZZA® can reduce double vision, as well eye pain redness and swelling.