Thyroid eye disease (TED), sometimes called Graves' ophthalmopathy or Graves’ Eye Disease, is an autoimmune disease in which the immune system causes inflammation and swelling and stimulates the production of muscle tissue and fat behind the eye. The overactive thyroid gland (hyperthyroidism) is usually caused by Graves' disease. Up to one-half of people with Graves’ disease develop thyroid eye disease. In some people, thyroid eye disease can occur with normal levels of thyroid hormones (euthyroid) or low levels of thyroid hormones (hypothyroidism). Thyroid eye disease may occur in patients who already know they have thyroid disease, or it may be the first sign of Graves’ disease. While TED often occurs in people living with hyperthyroidism or Graves’ disease, it is a distinct disease and treating hyperthyroidism may not resolve the eye symptoms and signs.
In the “active phase” of thyroid eye disease, the main symptoms include inflammation and increased amounts of the tissue, muscles, and fat behind the eye (in the bony eye socket) causing the eyeballs to bulge out. If the eye is pushed far enough forward, the eyelids may not close properly when blinking and sleeping. The front part of the eye, called the cornea, may become unprotected, dry and, damaged. Also, the enlargement of the tissues and muscles of the eye may prevent it from working well, which affects eye position and eye movements leading to double vision. In severe cases, the inflammation and enlargement of the tissues, muscles, and fat behind the eye compresses the optic nerve, the nerve that connects the eye to the brain, causing vision loss.
Thyroid eye disease is most commonly associated with Graves' disease. It can also occur with normal thyroid hormone levels or low levels of thyroid hormones (hypothyroidism).
Other risk factors for thyroid eye disease include:
If you have Graves’ disease, eye symptoms most often begin within six months of disease diagnosis. Very rarely, eye problems may develop long after the Graves’ disease has been treated. In some patients with eye symptoms, hyperthyroidism never develops and, rarely, patients may have hypothyroidism. The severity of the eye symptoms is not related to the severity of the hyperthyroidism.
Symptoms of thyroid eye disease are caused by the tissues, fat, and muscles of the eye socket swelling and pushing the eyeball forward. It may be possible that symptoms may appear in one eye more than the other. The symptoms of thyroid eye disease include:
Dry, gritty and irritated eyes
Sensitivity to light
Bulging eyes (called proptosis) and lid retraction - giving a staring or startled appearance
In more advanced thyroid eye disease, there may also be:
Trouble moving eyes and closing eyes
Inability to completely close your eye causing a corneal ulcer
Colors appear to be dull or not as bright
Blurred or loss of vision due to optic nerve compression or corneal damage
Thyroid eye disease in its active phase can last between one and three years. That means if it is left untreated, the inflammation may gradually decrease by itself but may cause damage to vision through the course of the disease. Sometimes, the changes caused by the enlargement of the tissues (such as bulging eyes or double vision) may not go away. The goal of treatment is to limit inflammation and swelling occurring during the active or inflammatory phase and to protect the front of the eye and prevent vision loss.
Thyroid eye disease is managed by a specialist eye doctor (ophthalmologist). Any underlying thyroid problems will be managed by your primary care doctor (PCP) or by a specialist in the hormone systems of the body (an endocrinologist).
If a thyroid issue is suspected, evaluation and treatment are critical. The first priority is to restore your normal thyroid function. In addition, eye conditions should be examined and treated at the same time as your thyroid gland treatment. Eye problems may continue to progress even after your thyroid function returns to normal.
If you have thyroid eye disease, your eye doctor may recommend one or more of the following treatments to help soothe your eyes and improve your vision:
Note: If you have difficulty closing your eyelids, you may be at risk to develop a corneal ulcer. The cornea is a clear layer that covers the front of the eye. A corneal ulcer is an open sore on your cornea and it can cause scarring and permanent loss of the vision. A corneal ulcer causes redness of the eye, pain and usually a decrease in vision. You should seek immediate attention from your eye doctor for these problems.
Your eye doctor will require some time for your thyroid eye disease to stabilize before recommending surgery. Typically, the active or inflammatory stage of thyroid eye disease lasts one to three years. During this time, your eye doctor will avoid surgically treating your symptoms unless your vision is threatened. In cases such as a corneal ulcer or optic nerve compression urgent surgery may be recommended.
Thyroid Gland: The thyroid gland is located in the front of your neck. It produces thyroid hormones that are sent to the blood and carried around to other parts of your body. These hormones help your body use energy, stay warm and keep the brain, heart, muscles, and other organs working normally. The thyroid gland can become overactive (hyperthyroidism) or underactive (hypothyroidism). This is most often due to an autoimmune disease in your body.
The Thyroid Gland
Hyperthyroidism: Hyperthyroidism is a condition where the thyroid gland is stimulated by the immune system to produce more thyroid hormones than are needed by the body. Symptoms may include weight loss, nervousness, irritability, increased perspiration, fast heart rate, hand tremors, difficulty sleeping, thinning of the skin, brittle hair, and frequent bowel movements.
Hypothyroidism: Hypothyroidism is a condition where thyroid gland function is blocked by the immune system and not enough thyroid hormone is produced for the body’s needs. Symptoms may include feeling cold and tired, having drier skin, becoming forgetful and depressed, and having constipation.
Autoimmune disease: If you have an autoimmune disease, your immune system mistakenly attacks your body. Autoimmune diseases can affect many parts of the body. The cause of autoimmune diseases is largely unknown.
Graves’ Eye Disease: Graves' Eye Disease is an autoimmune disease which primarily affects the thyroid gland. Other parts of the body may be affected, including eyes and skin. It is the most common cause of hyperthyroidism.
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