How Graves’ Disease Affects the Eyes

What are the symptoms of Graves’ ophthalmopathy?

Early symptoms of GO generally start around the same time as other symptoms of Graves’ disease, but eye problems develop first in about 25-50% of people with the disease. Rarely does GO develop long after treatment for Graves’ disease.

Symptoms of GO may include:

• dryness
• grittiness
• irritation
• pressure and pain
• redness and inflammation
• retracting eyelids
• bulging of the eyes, also called proptosis or exophthalmos
• light sensitivity
• double vision, also called diplopia

In severe cases, you might also have:

• trouble moving or closing your eyes
• exposure and ulceration of the cornea
• compression of the optic nerve

Rarely, GO can lead to vision loss.

Graves’ eye disease often affects both eyes. Up to 14% of the time, only one eye is involved.

For people with GO, there’s a period of active inflammation around the eyes during which symptoms worsen. This can last up to 6 months. Then, there’s an inactive phase in which symptoms stabilize or start to improve.

There’s no connection between your eye symptoms and the severity of hyperthyroidism.

What causes Graves’ ophthalmopathy?

The exact cause of GO isn’t clear, but it may be a combination of genetic and environmental factors.

The inflammation around the eye is due to an autoimmune response. With GO, the same abnormal immune response that triggers the thyroid gland in Graves’ disease affects the muscles and soft tissues around the eye. This leads your body to produce an inflammatory response.

Graves’ eye disease usually occurs along with hyperthyroidism, but not always. It can also happen when your thyroid isn’t currently overactive.

Risk factors for GO include:

• genetic influences
• smoking
• radioactive iodine therapy for hyperthyroidism

Females have a higher risk of developing GO than males, as they have a higher risk of autoimmune disease.

There’s no way to prevent Graves’ disease or Graves’ eye disease. But if you have Graves’ disease and you smoke, you’re more likely to develop eye disease than people who don’t smoke. Plus, eye disease tends to be more severe for those who smoke.

How is Graves’ ophthalmopathy diagnosed?

If you have Graves’ disease, a doctor can make a diagnosis of GO after an eye exam.

A specialized doctor called an ophthalmologist typically helps manage GO, while a primary care doctor or endocrinologist typically manages hormone treatment for Graves’ disease.

If you don’t already have a diagnosis of Graves’ disease, a doctor will likely examine your eyes and your neck to see whether your thyroid is enlarged.

They may order a blood test to check your thyroid-stimulating hormone (TSH) levels. TSH, a hormone produced in the pituitary gland, stimulates the thyroid to produce hormones. If you have Graves’ disease, your TSH level may be low, but you’ll typically have high levels of thyroid hormones.

Blood tests can also check for Graves’ antibodies. This test isn’t needed to make the diagnosis, but it may be done anyway. A doctor can start looking for another diagnosis if it turns out to be negative.

A doctor may also order imaging tests such as ultrasound, CT scan, or MRI for a detailed look at the thyroid gland.

A doctor may also order a radioactive iodine uptake. For this procedure, you’ll take some radioactive iodine and allow your body to absorb it. Later, a special scanning camera can help determine how well your thyroid takes in iodine. This helps inform the diagnosis of Graves’ disease.

How is Graves’ ophthalmopathy treated?

Treating Graves’ disease involves specific therapies to keep hormone levels within the normal range. Graves’ eye disease requires treatment since treating Graves’ disease doesn’t always help with eye symptoms.

One approved medication for active thyroid eye disease is teprotumumab (Tepezza). Research shows it can reduce symptoms of GO, including eye bulging and double vision.

You can also try a few things on your own to ease GO symptoms, including:

• Eye drops: Use drops that don’t contain redness removers or preservatives. Lubricating gels can also be helpful at bedtime if your eyelids don’t entirely close. An ophthalmologist can recommend products most likely to relieve dry, irritated eyes.
• Cool compress: For temporary relief of irritation, try gently pressing a cool compress on or around your eyes. This may be soothing just before you go to bed or when you first get up in the morning.
• Sunglasses: Sunglasses may help with light sensitivity and protect your eyes from wind or breezes from fans, direct heat, and air conditioning. Wraparound glasses may be more helpful outdoors.
• Prescription glasses: Glasses with prisms may help correct double vision. But they may not work for everyone.
• Extra head support: Sleeping with your head raised may reduce swelling and relieve pressure on the eyes.
• Corticosteroids: Steroids such as hydrocortisone or prednisone can help reduce swelling around your eyes but can also cause side effects. An ophthalmologist can determine whether they are right for you.
• Avoiding smoke: Smoking can make your eye symptoms worse. If you smoke, talk with a doctor about smoking cessation programs. You could also try avoiding secondhand smoke, dust, and other things that irritate your eyes.

Be sure to tell the ophthalmologist if nothing is working and you continue to have double vision, decreased vision, or other problems.

Some surgical interventions for GO can help, too. These include:

• Orbital decompression surgery: This procedure enlarges the eye socket so the eye can rest in a better position. This involves removing sections of paper-thin bone between the eye socket and sinuses to create space for swollen tissue.
• Eyelid surgery: This surgery returns the eyelids to a more natural position.
• Eye muscle surgery: This surgery helps correct double vision. It involves cutting muscle affected by scar tissue and reattaching it further back in your eye.

These procedures can help improve vision or the appearance of your eyes.

Rarely radiation therapy, called orbital radiotherapy, is used to reduce swelling in the muscles and tissues around the eyes. This is done over several days.

Other treatments may be more appropriate if your eye symptoms are unrelated to Graves’ disease.

Frequently asked questions

What are the first signs of Graves’ eye disease?

The first signs of Graves’ eye disease can include inflammation, irritation, and puffiness.

Can Graves’ eye disease be cured?

While there is no cure for Graves’ eye disease, treatment can help the disease stabilize or improve.

What foods should be avoided with thyroid eye disease?

If you have thyroid eye disease or thyroid disease, you may need to avoid foods and supplements containing iodine. These can include:

• kelp and seaweed
• iodized salt
• iodine supplements

How do I get rid of puffy eyes from thyroid eye disease?

Treating thyroid eye disease may help improve your symptoms. You can also try at-home remedies, such as applying a cold compress, using lubricating eye drops, and sleeping with your head elevated.

What’s the outlook?

GO is a medical condition with ups and downs. Treatment options may change depending on the severity of your symptoms. In general, GO can be successfully treated with medication, home remedies, or surgery.

Because the disease is so dynamic, a doctor likely won’t recommend surgery unless there’s a vision emergency.

Symptoms can improve even without treatment, but treatment can help lower the chance of permanent eye damage from inflammation. With proper treatment, symptoms of GO usually stabilize. They may start to improve immediately or remain stable for a year or two before they improve.

While the symptoms can be frustrating and disruptive to your everyday life, it’s very rare for GO to cause blindness, especially with proper treatment.

If you receive a diagnosis of Graves’ disease, consider finding an ophthalmologist to screen you for eye problems and let a doctor know right away if you have any bothersome eye symptoms.