Thyroid Eye Disease (TED)

(also known as Graves’ Orbitopathy or Thyroid Orbitopathy)

The thyroid gland (at the front of the lower part of the neck) produces a hormone called thyroxine. Thyroxine is crucial for our metabolism and well-being. Disorders of the thyroid gland can result in an underproduction or overproduction of thyroxine.

Thyroid eye disease encompasses a number of eye problems that can occur in association with abnormal thyroid gland function.

One of the commonest thyroid disorders is Graves’ disease, an autoimmune disorder that typically affects women in their thirties (but can affect anyone at any age). Graves’ disease results in an overproduction of thyroxine. For reasons that are not completely understood, the immune system not only attacks the thyroid gland but also attacks one or both of the eye sockets (orbits). This results in swelling of the fat and muscles in the orbits.

Thyroid eye disease encompasses a number of eye problems that can occur in association with abnormal thyroid gland function.

The most common thyroid-related problems that affect the eyes are:

  • Eyelid swelling & conjunctival swelling (chemosis)
  • Dry eye symptoms
  • Eyelid retraction (the upper and lower eyelids sit further apart and expose more of the eyeball) causing a starey eyed appearance
  • Bulgy and prominent looking eyes (proptosis)
  • Double vision (diplopia) – this can occur because the muscles that move the eyeball become swollen
  • Visual loss – pressure on the optic nerve or excessive exposure of the eye can reduce vision in a very small proportion of patients

Thyroid eye disease can occur before, during or after the onset of an abnormal level of thyroxine.

Although in most patients a blood test will confirm an abnormal thyroxine level, some patients can have features of TED with a normal level of thyroxine. These patients may have abnormal thyroid antibodies that can help confirm the diagnosis.

Thyroid eye disease usually has 2 phases:

  • Active phase – this is associated with swelling of the soft tissues around the eye and can include progressive prominence eyelid retraction and double vision. The active phase usually lasts 2-3 years
  • Inactive phase – although the soft tissue swelling settles this is often replaced by scarring of the orbital tissues and so the patient can be left with stable but significant problems due to an altered appearance (caused by protrusion of the eyeball, eyelid retraction, puffy eyelids with eyebags or misalignment of the eyes) or dry eyes due to incomplete eyelid closure (lagophthalmos) or permanent double vision.

The Thyroid Eye Disease Charitable Trust has some very useful information and contact information for help and advice on this condition. To find out more you can go to

Management of Thyroid Eye Disease

Treatment of the active phase

It is important for the thyroxine level to be corrected and this is best managed by an endocrinologist (a physician who specialises in treating hormone disorders). The endocrinologist and ophthalmologist will work closely together to manage the thyroid gland disorder and the TED.

Initial treatment of the active phase of TED can include:

  • Stopping smoking – smoking has been strongly linked to progression of TED so it is important to stop smoking to try to minimise the risk of progressive and permanent eye problems
  • Lubricants and cool compresses – can help alleviate eye discomfort and swelling
  • Selenium supplements – can help reduce the severity of mild active TED
  • Intravenous or oral steroids – can help reduce the activity of TED
  • Orbital radiotherapy – can help reduce progression of double vision in TED
  • Hyaluronic Acid filler injections (e.g. RestylaneTM) can be used to temporarily reduce upper & lower eyelid retraction and thus improve closure and comfort of the eyes
  • Botulinum toxin (e.g. BotoxTM, AzzalureTM) injections can be used to temporarily lower a retracted upper eyelid
  • Glaucoma treatment- the swollen orbital tissues may result in an unacceptably high pressure in the eyes (intraocular pressure) Glaucoma medication in the form of eyedrops may be needed to lower the intraocular pressure
  • Orbital surgery – rarely orbital decompression surgery is required to reduce pressure on the optic nerve or to reduce severe sight-threatening exposure of the eye

The eye and visual function should be carefully monitored by an ophthalmologist throughout the active phase of TED.

A CT or MRI scan of the orbits may be required to help confirm the diagnosis of TED and exclude other possible causes of a protruding eye (proptosis).

TTreatment of the inactive phase of TED

  • Orbital decompression surgery
  • Squint (strabismus) surgery for double-vision
  • Eyelid retraction surgery
  • Blepharoplasty

Orbital Decompression Surgery

Orbital decompression surgery involves removal of 1, 2 or 3 of the 4 walls of the bony orbit and/or orbital fat to create more space for the eyeball and other orbital tissues.

Orbital decompression surgery can:

  • Reduce the prominence of the eyeball
  • Reduce the degree of exposure of the eye
  • Reduce pressure on the optic nerve (and so help preserve vision)
  • Reduce congestion of the orbit and subsequent swelling of the soft tissues around the eye
  • Reduce deep orbital pain associated with TED

Click here for more information on orbital decompression surgery

Squint (strabismus) surgery

Thyroid eye disease can sometimes result in troublesome double vision. Orbital decompression surgery can cause or worsen double vision. If double vision persists it may require assessment and treatment by a squint specialist (an ophthalmologist who has specialised in the management of squint).

Some patients can be helped with botulinum toxin injections and others require surgery to improve the misalignment of their eyes.

Eyelid retraction surgery

TED can result in upper and lower eyelid retraction. Eyelid retraction can emphasise a starey eyed appearance and can result in incomplete eyelid closure (lagophthalmos) and dry eye problems.

Eyelid retraction can sometime improve after orbital decompression surgery. Squint surgery can sometimes improve upper eyelid retraction but can sometimes worsen lower eyelid retraction.

For the above reasons surgery to improve eyelid retraction should be performed after orbital decompression or squint surgery if these procedures are also required.

Click here for more information on eyelid retraction surgery.


TED can result in marked changes to the eyelids and facial appearance. Enlargement of the orbital fat can result in the appearance of puffy lower eyelid bags. The swelling of the eyelids in the active phase and subsequent resolution can leave behind redundant skin in the upper and lower eyelids. Blepharoplasty can help address both of these problems to help restore a patient’s pre-TED appearance.

Click here for more information on blepharoplasty surgery

Your consultation

The success and safety of your eyelid surgery procedure depends very much on your complete candidness during your cosmetic eyelid surgery consultation. You'll be asked a number of questions about your health, desires and lifestyle.

Please be prepared to discuss:

  • Why you want the surgery, your expectations and desired outcome
  • Medical conditions, drug allergies and previous medical treatments
  • Use of current medications, vitamins, herbal supplements, alcohol & tobacco
  • Previous surgeries

The following will also take place at your consultation

  • Evaluation of your general health and any pre-existing health conditions or risk factors
  • An assessment of your vision and a thorough eye examination including a slit-lamp examination of the eye.
  • Photographs for your medical record
  • A discussion about treatment options
  • Recommendations for treatment most appropriate for you
  • Discussion about likely outcomes of eyelid surgery and risks or potential complications
  • The type of anaesthesia that will be used (This is usually “Twilight anaesthesia” using local anaesthesia with intravenous sedation administered by a consultant anaesthetist. However, a full general anaesthetic can be arranged if you prefer this option)

After the consultation I will send you a letter summarising your concerns and desires relating to your appearance along with my assessment and advice to you regarding treatment options.

You will also receive a quote for your proposed surgery and have the opportunity to attend for a further consultation prior to proceeding should you wish to ask any further questions.

Arrange a consultation