11/14/24, 10\:40 AM Thyroid Eye Disease

Thyroid Eye Disease

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Thyroid eye disease (TED)\: autoimmune condition causing in
tissue, and connective tissue within the orbit; most common cause of unilateral/bilateral exophthalmos in adults, more
common in females.
Aetiology\: commonly occurs with Graves' disease but can present in euthyroid or hypothyroid patients. Elevated antibodies
against TSH receptors in orbital fat and connective tissue; increased
accumulation cause muscle enlargement and
Risk factors\: smoking, previous radioiodine therapy, men have more severe disease.
Symptoms\: excessive watering, gritty sensation, photophobia, eye pain, red eye, blurred vision, pressure sensation,
systemic signs of thyroid disease (e.g., pretibial myxoedema, goitre).
Clinical
commonly inferior rectus), incomplete eyelid closure, compressive optic neuropathy (reduced visual acuity, colour vision,
contrast sensitivity).
Investigations\:
Laboratory\: thyroid function tests (raised T3/T4, low TSH in hyperthyroidism), antibody testing (TSH-receptor antibodies,
thyroid-stimulating antibody, TSH-binding inhibitory immunoglobulins, thyroid peroxidase antibodies).
Imaging\: ultrasound (detects muscle enlargement), CT orbits (detects optic nerve involvement, images orbital bones), MRI
orbits (alternative to CT with reduced ionisation risk).
Diagnosis\: based on clinical signs, history, and specialised tests; EUGOGO classi
Management\:
Correct thyroid hormone levels to achieve euthyroidism in hyperthyroid patients.
Smoking cessation advice.
Arti
Steroids (IV methylprednisolone) for severe cases, especially compressive optic neuropathy.
Surgery (orbital decompression, lid surgery) for signi
Complications\: loss of sight (compressive optic neuropathy), globe subluxation, gaze abnormalities, raised intraocular
pressure (glaucoma).
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Introduction

Thyroid eye disease (TED) is an autoimmune condition resulting in in
fatty tissue and connective tissue within the orbit.
It is the most common cause of unilateral and bilateral exophthalmos in adults and more common in females.
1
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Aetiology

TED commonly occurs in patients with Graves' disease but can present in euthyroid or hypothyroid patients. In most
patients, eye disease and thyroid issues evolve within 1.5 years of each other.
For more information on Graves' disease, see the Geeky Medics guide to thyrotoxicosis and hyperthyroidism.

Pathophysiology

Closely correlating with Graves’ disease, patients with TED have been found to have elevated levels of antibodies against
thyroid-stimulating hormone (TSH) receptors, which are expressed in orbital fat and connective tissue.
Studies also attribute increased
enlargement and
2

Risk factors

Risk factors for thyroid eye disease include\:
Smoking
Previous radioiodine therapy
Men have more severe disease

Clinical features

History

Typical symptoms of thyroid eye disease include\:
Excessive watering
‘Gritty’ sensation
Photophobia
Eye pain
sensation of pressure.
Other important symptoms to ask in the history include red eye, blurred vision (due to incomplete eyelid closure) and
Patients may also present with systemic signs of thyroid disease, such as pretibial myxoedema, goitre and acropachy.

Clinical examination

Typical clinical
Eyelid retraction (Dalrymple’s sign)
Proptosis
Lid lag (Von Graefe’s sign)
Lid oedema
Diplopia due to restriction of extraocular muscles, most commonly inferior rectus
Incomplete eyelid closure
In a small portion of patients, the enlarged muscles and fat can press on the optic nerve, resulting in compressive optic
neuropathy. Patients report reduced visual acuity, colour vision and contrast sensitivity. If this is not treated urgently, it can
be sight-threatening.
While most patients have mild manifestations of TED, optic nerve compressing TED is one of the rare presentations in
ophthalmology where urgent intravenous methylprednisolone is required. Hence, it is essential to check the
measurement of proptosis and assess optic disc, visual acuity, colour vision and relative a
assessment.
3,4
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Figure 1. Proptosis and eyelid retraction.
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Mnemonic\: NO SPECS
The mnemonic ‘NO SPECS’ can be used to recall the features of thyroid eye disease.
N\: No signs or symptoms
O\: Only ocular irritation (dryness, gritty sensation)
S\: Soft tissue involvement (conjunctival oedema or injection)
P\: Proptosis
E\: Extraocular muscle involvement
C\: Corneal exposure and ulceration
S\: Sight loss (due to compressive optic neuropathy)

Investigations

Laboratory investigations

Relevant laboratory investigations include\:
3
Thyroid function tests\: raised T3 and/or T4 and low TSH levels in patients with hyperthyroidism
Antibody testing\: TSH-receptor antibodies, thyroid-stimulating antibody and TSH-binding inhibitory immunoglobulins
and thyroid peroxidase antibodies - may be raised in patients with normal thyroid function tests

Imaging

Several imaging modalities can be used to con
and high myopia (short-sightedness).
4
Relevant imaging investigations include\:
Ultrasound scan\: detects extraocular muscle enlargement
CT orbits\: useful to detect optic nerve involvement and image orbital bones for surgery planning
MRI orbits\: an alternative to CT scan with reduced ionisation risk (Figure 2)
Figure 2. MRI of the orbit showing
enlarged extraocular muscles.
6

Diagnosis

The diagnosis of thyroid eye disease is based on clinical signs, history and specialised tests. There are multiple
classiEuropean Group on Graves’ Orbitopathy (EUGOGO) classi
most used in Europe.
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Management

Patients are typically managed with input from both ophthalmology and endocrine specialists.
In patients with hyperthyroidism, thyroid hormone levels should be corrected to achieve euthyroidism.
Smoking cessation advice should be given to reduce the risk of further exacerbations. If patients are reporting symptoms
from corneal exposure, arti
In severe cases, steroids can be used to reduce in
compressive optic neuropathy. Some patients may require surgery, such as orbital decompression and lid surgery, if there
is signi
1,3

Complications

Complications of thyroid eye disease include\:
Loss of sight secondary to compressive optic neuropathy
Globe subluxation\: eye ‘popping out’
Gaze abnormalities
Raised intraocular pressure leading to glaucoma

References

Weiler D. T h y r o i d e y e d i s e a s e \: a r e v i e w . 2016. Available from\: [LINK]
Garrity J and Bahn R. P a t h o g e n e s i s o f G r a v e s O p h t h a l m o p a t h y \: I m p l i c a t i o n s f o r P r e d i c t i o n , Available from\: [LINK]
P r e v e n t i o n , a n d T r e a t m e n t . 2006.
EyeWiki. T h y r o i d E y e D i s e a s e . Available from\: [LINK]
Bahn R. G r a v e s’ O p h t h a l m o p a t h y . 2010. Available from\: [LINK]
CNX OpenStax. O S C M i c r o b i o 1 9 0 2 e x o p h t h . License\: [CC BY 4.0]
Tran H and Reeves G. G r a v e s O p h t h a l m o l o g y M R T 0 1 . License\: [CC BY-SA 2.0]

Reviewer

Consultant Ophthalmologist

Acromegaly
Addison's Disease (Primary Adrenal Insu
Cushing's Syndrome
Diabetes Insipidus
Growth Hormone De

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