Condition: Thyroid eye disease (TED) – grave´s disease2019-04-04T16:22:03+00:00

Thyroid eye disease (TED) – Grave’s disease

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There are different treatment options available for this condition and the most common ones are listed below:

  • Thyroid eye disease (TED)
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Thyroid eye disease (TED)

What is a Thyroid eye disease?

Graves’ disease is most commonly referred to as Thyroid Eye Disease (TED), also known as Graves’ orbitopathy. The exophthalmos is most commonly associated with hyperthyroidism with a goitre, known as Graves’ disease or von Basedow’s syndrome.


Patients with TED experience a change in the appearance of their eyes and periorbital area. The eyes protrude (exophthalmos) and vision may be affected by optic nerve compression, particularly in the acute phase; the ocular surface may become exposed, dry and painful.

The patient may have double vision (diplopia) and abnormally retracted eyelids. The oculoplastic surgeon is one of the main people involved in the rehabillitation of patients with thyroid eye disease, working closely with their endocrinologist.

TED is a relatively common condition arising from an autoimmune disorder. It has an active, or ‘wet’, phase and an inactive, or ‘dry’ phase, when the signs and symptoms stabilise and even improve slightly.

Active TED

Symptoms can either be mild (some swelling of the eyelids) or more severe (increased puffiness around the eyes, redness, “jelly-like” appearance on the white of the eye, and marked protrusion or proptosis). If muscles are affected this can cause double vision and the optic nerve can be compressed or stretched and threaten vision. Eyelids may widen (eyelid retraction), giving a staring appearance. There is generalised periorbital fullness with proptosis and

If muscles are affected this can cause double vision and the optic nerve can be compressed or stretched and threaten vision. Eyelids may widen (eyelid retraction), giving a staring appearance. There is generalised periorbital fullness with proptosis and

There is generalised periorbital fullness with proptosis and protrusion of the orbital fat which appears as prominent eyebags. The orbits typically ache on eye movement, described by some patients as a stiffness and sluggishness when moving the eyes.

Eyelid retraction can also cause painful ocular exposure with photophobia and dry eye. Reflex watering from surface discomfort and poor drainage of tears due to the tight eyelids occurs. Rarely, the exposed front of the eye (cornea) ulcerates and scars which threatens vision.

If muscles are affected this can cause double vision and the optic nerve can be compressed or stretched and threaten vision. Eyelids may widen (eyelid retraction), giving a staring appearance.

Active thyroid eye disease is managed medically with immunosuppression. However, if there is compressive optic neuropathy, surgical orbital apex decompression is indicated. Control of thyroid hormone levels and avoidance of smoking is paramount in order to moderate the severity of active thyroid eye disease.

Inactive phase of TED

The active phase lasts between six and twelve months, during which the symptoms and signs of thyroid eye disease become established. Therefore, the symptoms and signs of the inactive phase are similar to those of active TED but less severe. Proptosis, double vision and sore, dry eyes may still be present.

At this stage, rehabilitation of the periorbita and face in thyroid eye disease is undertaken. This may involve a series of operations on the orbit, eye muscles, eyelids and periorbital soft tissue, in order to improve the patient’s orbital and ocular discomfort as well as cosmesis.


As the appearance of TED is fairly unique, its diagnosis is relatively simple. Desipte this, the diagnosis is often overlooked. Patients with TED are referred to the oculoplastic surgeon from a range of medical fields: their GP, endocrinologist or another ophthalmologist.

The principal role of the oculoplastic surgeon is to monitor the patient’s vision and help maintain ocular comfort whilst in the acute phase and for surgical rehabilitation of the orbit and eyelids once the patient is in the stable or inactive phase of thyroid eye disease.

At the beginning, if an overactive gland is suspected, the thyroid function is evaluated by a blood test and any abnormality of hormone level treated by an endocrinologist.

In order to know at what stage the TED is, a thorough history is taken, visual function is assessed and orbital and eyelid measurements are taken. Photographic documentation is made. The patient provides photographs of their appearance prior to the onset of TED symptoms.

Specific tests include a colour vision test, assessment of the amount of orbital protrusion (exophthalmos), measurement of how wide open the eyelids are, and assessments of how much periorbital swelling is present. The front of the eye is examined with a slit lamp, the pressure of the eye is measured, and the back of the eye is examined to check the optic nerve. Eye drops are used which may blur vision for a few hours.

Visual field analysis may be performed to assess optic nerve function, including any visual loss from optic neuropathy.

An orthoptist will carry out eye muscle measurements if double vision is present.
A CT scan is often done to show the orbit, and any changes to it, which helps plan treatment.

All of the above findings are compiled to provide a score (CAS/VISA scores) of the severity of the disease and degree of activity, which helps guide treatment whether medical or surgical.


TED has an initial active phase that lasts between 6 and 18 months. During this period it may worsen, then start to show some improvement spontaneously as it enters the inactive or stable phase.

It should be monitored carefully by an oculoplastic surgeon.

Non-surgical treatment of active TED

Lubricant eye drops make the eye more comfortable and protect the cornea and should be used regularly by TED patients.

Non-surgical treatment is planned according to the degree of thyroid activity, sometimes using steroids or low-dose radiotherapy.

If visual function is severely threatened because the optic nerve is compressed, either a high dose of steroids or urgent orbital decompression is required. Pulse methylprednisolone is given intravenously to manage active thyroid eye disease with proptosis, soft tissue inflammation, diplopia or early optic neuropathy.

Surgical treatment of active TED

If the visual acuity, colour vision and visual field are markedly affected, indicating compressive optic neuropathy, surgical orbital apex decompression is mandatory.

Surgical treatment of inactive TED

Surgical treatment is usually started when the disease is stable. TED surgery is used to correct the proptosis, ocular exposure, double vision and periocular and orbital bulkiness and eyebags.

Surgery is performed by the oculoplastic surgeon in the following order:

1. Orbital decompression is balanced to correct eye protrusion and orbital bulkiness
2. Eye muscle surgery is performed to correct double vision
3. Eyelid surgery is performed to correct eyelid retraction
4. Augmented blepharoplasty for eyebags by peri-ocular debulking and soft-tissue orbital decompression.

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