Understanding Thyroid Eye Disease (Graves’ Ophthalmopathy)

What Is Thyroid Eye Disease?

Thyroid Eye Disease (TED), also called Graves’ ophthalmopathy, is an autoimmune condition that affects the tissues around the eyes. It most often occurs in people with Graves’ disease, an overactive thyroid condition caused by stimulating antibodies. However, TED can also develop in people who are euthyroid or even hypothyroid.

In TED, the immune system mistakenly attacks the muscles and connective tissues behind the eyes. This leads to inflammation, swelling, and sometimes scarring. These changes can push the eyes forward (proptosis), cause double vision (diplopia), or even threaten vision if left untreated.

Who Is at Risk?

TED affects up to 50% of individuals with Graves’ disease. However, only a minority develop severe forms. Risk factors include:

• Smoking: The most important modifiable risk factor.
• Female sex: Though men may develop more severe disease.
• Middle age: Typically between 40 and 60 years.
• Uncontrolled thyroid dysfunction: Especially ongoing hyperthyroidism.
• Radioactive iodine therapy (RAI): In some, this can trigger or worsen eye disease.

Importantly, patients with a history of autoimmune thyroid disease should stay alert to early eye symptoms.

Early Signs and Symptoms

TED often starts gradually. Early symptoms may mimic common eye issues, making early recognition difficult. Typical signs include:

• Eye dryness or excessive tearing
• A gritty or foreign body sensation
• Puffy eyelids
• Redness around the eyes
• Light sensitivity
• Difficulty fully closing the eyes

As the condition progresses, patients may develop more visible or serious changes, such as:

• Proptosis (eye bulging)
• Double vision
• Eye pain or pressure
• Restricted eye movement
• Vision loss (in severe cases)

Phases of TED: Active vs. Inactive

TED follows a well-recognized clinical course, usually divided into two phases:

• Active Phase: This early phase involves active inflammation and can last 6–24 months. During this stage, inflammation worsens, and symptoms fluctuate. Timely treatment can prevent long-term damage.
• Inactive Phase: Once inflammation subsides, the disease enters a stable phase. At this point, tissue changes (like fibrosis or muscle restriction) may persist, requiring surgical correction.

Understanding this distinction helps guide treatment timing and strategy.

How TED and Thyroid Disease Interact

Graves’ disease is the most common cause of hyperthyroidism and strongly associated with TED. Both result from TSH receptor antibodies, which stimulate the thyroid and also activate orbital fibroblasts.

Interestingly, TED severity does not always correlate with the degree of thyroid dysfunction. Some patients with well-controlled or even hypothyroid states still experience active eye disease.

That said, stable thyroid function is crucial for optimal TED outcomes. Both over- and under-treatment of thyroid hormone can worsen inflammation.

Diagnosis and Evaluation

Diagnosis of TED is primarily clinical, based on history and physical exam. Important steps include:

• Ophthalmologic evaluation: To assess proptosis, eye movement, and visual acuity.
• Thyroid panel: TSH, free T4, and T3 levels.
• Thyroid-stimulating immunoglobulins (TSI) or Thyrotropin receptor antibodies (TRA): These help confirm Graves’ disease.
• Orbital imaging (CT or MRI): Used when symptoms are severe or atypical.

A multidisciplinary approach—often involving an endocrinologist, an ophthalmologist, and sometimes a surgeon—is ideal.

Treatment Strategies

TED management depends on the disease phase and symptom severity. Approaches include:

1. Stabilizing Thyroid Function: Achieving and maintaining a euthyroid state is critical. This often involves antithyroid medications, surgery, or radioactive iodine. If RAI is used, concurrent steroid therapy may reduce TED flare-ups.
2. Supportive Care: Especially during the active phase:Artificial tears or gelsSunglasses for light sensitivityElevating the head at nightSelenium supplementation in mild cases
3. Immunosuppressive Therapy: For moderate to severe active disease: Steroids (oral or IV): First-line for acute inflammation. Teprotumumab: A newer FDA-approved therapy that targets IGF-1R on orbital fibroblasts. It can reduce proptosis and inflammation. Radiotherapy: Occasionally used to reduce orbital swelling.
4. Surgical Interventions: Considered during the inactive phase: Orbital decompression: Reduces eye bulging. Strabismus surgery: Corrects double vision. Eyelid surgery: Improves lid retraction or exposure symptoms.

Why Holistic, Individualized Care Matters

TED is not just a cosmetic issue. It affects vision, comfort, confidence, and quality of life. At our Montgomery County practice, we provide personalized thyroid care that sees TED in its broader context—autoimmunity, hormone imbalances, metabolic risks, and emotional well-being.

For example, smoking cessation is a cornerstone intervention. Likewise, treating concurrent hypothyroidism, insulin resistance, or adrenal fatigue may support recovery. We aim to manage TED from multiple angles, not just the eyes.

Summary Table – Thyroid Eye Disease Overview

Takeaway

Thyroid Eye Disease is a complex condition that requires more than eye drops or a referral. With thoughtful, holistic care, many patients can avoid long-term damage and regain comfort and confidence. If you’ve been diagnosed with TED or Graves’ disease, we offer comprehensive endocrine guidance tailored to your unique needs.

Dr. Tashko

References:

1. Thyroid Eye Disease (Graves’ Orbitopathy): Clinical Presentation, Epidemiology, Pathogenesis, and Management. Wiersinga WM, Eckstein AK, Žarković M. The Lancet. Diabetes & Endocrinology. 2025;:S2213-8587(25)00066-X. doi:10.1016/S2213-8587(25)00066-X.
2. Current Concepts Regarding Graves’ Orbitopathy. Bartalena L, Tanda ML. Journal of Internal Medicine. 2022;292(5):692-716. doi:10.1111/joim.13524.
3. Teprotumumab for the Treatment of Active Thyroid Eye Disease. Douglas RS, Kahaly GJ, Patel A, et al. The New England Journal of Medicine. 2020;382(4):341-352. doi:10.1056/NEJMoa1910434.
4. Comprehensive Comparisons of Different Treatments for Active Graves Orbitopathy: A Systematic Review and Bayesian Model-Based Network Meta-Analysis. Xu Y, Liu R, Huang L, et al. The Journal of Clinical Endocrinology and Metabolism. 2025;110(6):1792-1801. doi:10.1210/clinem/dgae877.
5. New Insights Into the Pathogenesis and Nonsurgical Management of Graves Orbitopathy. Taylor PN, Zhang L, Lee RWJ, et al. Nature Reviews. Endocrinology. 2020;16(2):104-116. doi:10.1038/s41574-019-0305-4.
6. Understanding Pathogenesis Intersects With Effective Treatment for Thyroid Eye Disease. Smith TJ. The Journal of Clinical Endocrinology and Metabolism. 2022;107(Suppl_1):S13-S26. doi:10.1210/clinem/dgac328.

About Dr. Gerti Tashko, MD

Dr. Gerti Tashko, MD, is a board-certified endocrinologist based in Montgomery County, Maryland. He is uniquely certified in endocrinology, lipidology, hypertension, and obesity medicine. His practice offers comprehensive, root-cause-focused metabolic and endocrine care, available both virtually and in person. He uses advanced diagnostics, personalized nutrition, and preventive medicine to optimize long-term health outcomes.