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Thyroid Eye Disorders

What is the thyroid?

The thyroid gland is located at the base of the front of the neck below the larynx ("voice box"). It absorbs iodine from the blood and produces two hormones, thyroxine and triiodothyronine. It plays an important role in regulating body metabolism.

What are euthyroid, hyperthyroid, and hypothyroid?

Normal thyroid hormone level in the blood is considered euthyroid. When the thyroid gland malfunctions, it can produce either too much hormone (hyperthyroid) or too little (hypothyroid). Either imbalance can cause a variety of symptoms. When abnormal hormone production is associated with an offending antibody, eye symptoms can develop (Graves disease).

Fig. 1

What are the symptoms of hyperthyroidism?

Typical symptoms of hyperthyroid include fatigue, fast heartbeat, weight loss, heat intolerance, thinning hair and diarrhea. Hypothyroid may also cause fatigue, but with slow heartbeat, constipation and weight gain.

Who gets thyroid eye disease?

Although thyroid eye disorders occur at any age, the average age at onset is 45 years. There are three times as many females with thyroid eye disorders.

What causes thyroid eye disease?

Normal body immune systems distinguish clearly between body tissue and foreign tissue/substances. Autoimmune disorders are characterized by the body production of antibodies against normal tissue. Graves disease is caused by an abnormal antibody attack on the thyroid gland which often results in over or under production of thyroid hormone. This same antibody can attack eye tissues and cause various eye symptoms.

Fig. 2

Does the thyroid abnormality itself cause eye disease?

No, the thyroid problems and the eye problems are independent manifestations of the underlying autoimmune abnormality. It is important to realize that thyroid eye disease can occur even when a patient is euthyroid.

What are the symptoms of thyroid eye problems?

Nearly all of the symptoms from thyroid eye disease arise as a result of swollen tissue around the eye. Eye watering, light sensitivity (photophobia), eyelid swelling and retraction of the eyelid are typical early symptoms [See figures 1 and 2].

Swelling of the normal fat tissue in the eye socket can push the eye forward creating variable prominence or protrusion of one or both eyes (proptosis). Proptosis can stretch and/or compress the optic nerve potentially causing blurred vision, impaired color vision and permanent vision loss. The swelling may also involve the muscles around the eyeball resulting in decreased ability to freely move the eye/eyes in various directions. This can cause eye fatigue, eye soreness and most notably double vision (diplopia).

How is thyroid eye disease treated?

If a thyroid disorder is suspected, appropriate evaluation and treatment are indicated. The first priority is to restore the euthyroid condition. Sometimes the eye problems continue to progress even after the thyroid abnormality is returned to normal. Eye problems should be evaluated and treated by an ophthalmologist.

There are typically two phases of eye treatment for thyroid eye disorders. The first phase involves treating the active eye disease and focuses on preserving sight. Cornea drying/exposure often require frequent application of artificial tears, tear duct plugs or taping the eyelids shut at night. Diplopia is treated with prism in spectacles and/or patching one eye. Potentially sight threatening compression of the optic nerve may require orbital decompression surgery. Removal of portions of orbital bones creates more "space" in the orbit, relieving compression on the optic nerve while reducing proptosis. Radiation of the orbit or high doses of anti-inflammatory steroids can also sometimes utilized for the initial, acute phase of orbital swelling. The active period, which may last up to several years, requires careful monitoring until this phase stabilizes.

The second phase of treatment involves correction of stable, non-changing fibrotic changes of periocular tissue which include proptosis, strabismus (causing double vision), and eyelid retraction. Orbital decompression surgery is sometimes performed to address disfiguring proptosis, even if vision is not compromised. Because decompression surgery can alter/create strabismus and/or change eyelid position, it is preferable to perform decompression surgery before strabismus or eyelid surgery.

Stable diplopia can be improved with prism spectacles (small misalignment) and/or surgery if the strabismus misalignment is larger. Strabismus surgery involves repositioning fibrotic eye muscle/s to better align the eyes.

Eyelid retraction can be improved with surgery that relaxes eyelid muscles and/or inserts spacer material to reposition the eyelid. Eyelid surgery is best performed after decompression and/or strabismus surgery.

Where can I get more information about thyroid eye disease?

National Graves Disease Foundation
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