Thyroid eye disease: symptoms, causes and treatment

What is thyroid eye disease?

It is also called Graves’ orbitopathy. The immune system attacks connective tissue around the eye muscles and orbital fat, causing swelling, eyelid retraction, bulging (proptosis), double vision and, rarely, optic nerve compression [1].

Who gets thyroid eye disease and why?

Up to 4 in 10 people with Graves’ disease develop thyroid eye disease. Moderate-to-severe disease occurs in about 6% and sight-threatening disease in about 0.5%. Smoking, unstable thyroid function, radioactive iodine treatment, male sex and age over 50 raise risk or severity. Smoking is the most important one you can change. Antibodies against the thyroid-stimulating hormone (TSH) receptor are almost always present in the blood and help confirm Graves’ disease [1, 2, 9].

What are the symptoms of thyroid eye disease?

• Retracted upper eyelid, giving a staring look: more than 9 in 10 patients.
• Bulging eyes, the second most common sign.
• Red, swollen lids and conjunctiva; pain behind the eye or on side gaze.
• Dry eye, gritty feeling, light sensitivity.
• Double vision, mostly looking up or to the side [1, 2].

How does thyroid eye disease progress?

There is an active inflammatory phase, a short static phase and an inactive phase, usually reached 12 to 18 months after onset. In the inactive phase the inflammation improves, but bulging and eye-movement problems can persist in up to half of patients who do not receive treatment [1].

How is thyroid eye disease diagnosed?

The ophthalmologist checks vision, colors, eye movements, eyelid position and how far the eye protrudes. To tell whether the disease is active, a list of 7 signs of inflammation (Clinical Activity Score, CAS) is used; 3 or more means the disease is considered active. If in doubt, the exam is repeated after 4 to 6 weeks. Depending on the case, laboratory or imaging tests are ordered before starting or continuing treatment [1].

How is thyroid eye disease treated?

Treatment depends on whether the disease is active and how severe it is. It is decided by an endocrinology and ophthalmology team [1].

Medical (non-surgical) treatments

• Local measures: artificial tears, night gel and prisms (special lenses for double vision); smoking cessation.
• Selenium for 6 months, in mild disease.
• Intravenous corticosteroids, in active moderate-to-severe disease.
• Biologic therapy: teprotumumab (FDA-approved in the US since January 2020, not yet available in Mexico, Oct 2026) and, as second-line options, rituximab or tocilizumab.
• Orbital radiotherapy, in selected cases with progressive double vision [1, 2].
• Steroid injection (triamcinolone or betamethasone) in the muscles that lift the eyelid, for eyelid retraction; usually 2 to 4 monthly sessions; efficacy is variable [3–5, 8].
• Botulinum toxin injection for eyelid retraction: it works in 2 to 3 days and lasts about 6 weeks; combined with the steroid it acts faster; both injections can be used during the active phase [6–8].

Which symptoms and signs can improve with medication

• Burning, dry eye and tearing: artificial tears and night gel.
• Redness, swelling and pain of the active phase: intravenous corticosteroids.
• Bulging and double vision of the active phase: teprotumumab, which is not yet available in Mexico (Oct 2026) [1, 2].

When is surgery done?

Rehabilitative surgery is done when disease is inactive and thyroid function has been stable, usually 4 to 6 months, depending on each case. It is staged: first the orbit so the eye returns to its position, then the muscles to align the gaze, and finally the eyelids. Not everyone needs all three. Occasionally an urgent decompression is needed, when vision drops because of optic nerve compression [1, 2].

• Orbital decompression: gives the eye more room by removing fat or parts of the bone. Its risks include cerebrospinal fluid leak, oscillopsia (shaky vision), cheek numbness and new double vision.
• Strabismus surgery: aims to restore single vision when looking straight ahead.
• Eyelid surgery: corrects the retraction and the protruding fat [1, 2].

Dr. Diener performs orbital decompression and eyelid surgery; strabismus surgery is done together with strabismus specialists. He also offers local TED treatments such as steroid and botulinum toxin injections, among others.

When to go to the emergency room

See an ophthalmologist immediately for reduced vision, washed-out colors, a blind spot, rapidly worsening vision, severe pain on eye movement, or an eye that will not close and becomes ulcerated [1].

Optic neuropathy occurs in 5 to 10 of every 100 cases and is treated urgently with high-dose intravenous corticosteroids; if vision does not improve, orbital decompression is considered [1, 2].

Prior evaluation, alternatives and risks

Before any treatment, a complete evaluation and clinical history are carried out, and with them the right treatment is chosen for each patient. In mild cases there is always the alternative of monitoring and using local measures. Each treatment has its own risks and benefits [1, 2].

FAQ

More information: orbital surgery · recovery tips · insurance providers.

Signed: Dr. Sebastián Diener, ophthalmologist and oculoplastic surgeon; professional license 11031816 (ULSA); specialty license 12354611 (UNAM); certified by the Mexican Council of Ophthalmology. Last medical review: October 19, 2026.

References

General information; it does not replace a medical evaluation.