All too visible: The physical damage of TED is devastating
The long-term impact of TED, including serious vision impairment, can be shattering. TED can reduce the patient’s independence, ability to work, and self-confidence.12,19 Even early Active TED can have a substantial negative effect on patients and once TED has become inactive, multiple surgeries may be necessary to correct the damage.7,11 These procedures are often only partially successful and can have significant impact on the lives of patients and their families.11
An early sign of Active TED is retraction of the eyelids. This may lead to lagophthalmos or the inability to fully close the eyes. The resulting corneal and conjunctival exposure can lead to dry eye symptoms and, for some patients, ulcerations and infections.7
Bilateral exophthalmos and upper eyelid retraction with lower eyelid edema
Proptosis or exophthalmos
Proptosis or exophthalmos is the bulging of the eyes that can prevent full closure of the eyelids, exposing the cornea.7 Corneal ulceration, pain, and sleeplessness are often the result. The bulging also changes patients’ physical appearance.
In addition to affecting self-perception, strabismus or misalignment of the eyes can also interfere with visual acuity.7,20 For many patients, multiple surgeries to correct strabismus and other TED-related conditions are needed.11
in the same study (n=128) said that visual function changes caused by TED severely limit their ability to engage in hobbies or pastimes.20
Commonly arising from strabismus, double vision is one of the most debilitating symptoms of TED. It causes significant functional impairment for patients, inhibiting their ability to drive, read, or watch TV.20
A controlled, descriptive study found German patients with TED and diplopia had significantly worse perceptions of their general health than those with TED but no diplopia (P<0.001; N=102).21
Vision loss / Optic neuropathy
Inflammation and the enlargement of muscles and adipose tissue around the orbit that begin during Active TED can create pressure on the optic nerve, potentially leading to loss of sight.7 Orbital decompression surgery may be needed to mitigate this.11
with TED who underwent orbital decompression surgery had substantial post-surgical limits to their eye movement (ductions decreased >5° in at least one meridian) in a retrospective cohort study conducted at a US orbital clinic.11
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- Bahn RS. Graves' ophthalmopathy. N Engl J Med. 2010;362:726-738.
- Mamoojee Y, Pearce SHS. Natural History. In: Wiersinga WM, Kahaly GJ (eds): Graves’ Orbitopathy: A Multidisciplinary Approach – Questions and Answers. Basel, Karger. 2017:93-104.
- Bartley GB. The epidemiological characteristics and clinical course of ophthalmopathy associated with autoimmune thyroid disease in Olmsted County, Minnesota. Tr Am Ophth Soc. 1994;92:477-588.
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- Perros P, Crombie AL, Matthews JN, Kendall-Taylor P. Age and gender influence the severity of thyroid-associated ophthalmopathy: a study of 101 patients attending a combined thyroid-eye clinic. Clin Endocrinol (Oxf). 1993;38(4):367-372.
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- Kilicarsan R, Alkan A, Ilhan MM, et al. Graves’ ophthalmopathy: the role of diffusion-weighted imaging in detecting involvement of extraocular muscles in early period of disease. Br J Radiol. 2015;88(1047):20140677.
- Smith TJ, Hegedüs L. Graves’ disease. N Engl J Med. 2016;375:1552-1665.
- Villadolid MC, Yokoyama N, Isumi M, et al. Untreated Graves’ disease patients without clinical ophthalmopathy demonstrate a high frequency of extraocular muscle (EOM) enlargement by magnetic resonance. J Clin Endocrinol Metab. 1995;80(9):2830-2833.
- Rootman DB, Golan S, Pavlovich P, Rootman J. Postoperative changes in strabismus, ductions, exophthalmometry, and eyelid retraction after orbital decompression for thyroid orbitopathy. Ophthal Plast Reconstr Surg. 2017;33:289-293.
- Ponto KA, Merkesdal S, Hommel G, Pitz S, Pfeiffer N, Kahaly GJ. Public health relevance of Graves’ orbitopathy. J Clin Endocrinol Metab. 2013;98:145-152.
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- Park JJ, Sullivan TJ, Mortimer RH, Wagenaar M, Perry-Keene DA. Assessing quality of life in Australian patients with Graves' ophthalmopathy. Br J Ophthalmol. 2004;88:75-78.
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- Yang DD, Gonzalez MO, Durairaj VD. Medical management of thyroid eye disease. Saudi J Ophthalmol. 2011;25:3-13.
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- Yakopson VS, Carrasco JR, Sharma P, Rabinowitz MP, Stefanyszyn MA. Effect of intraorbital steroid injections on intraocular pressure in thyroid eye disease. Thyroid Disorders Ther. 2015;4(1):1000173.
- Gillespie EF, Smith TJ, Douglas RS. Thyroid eye disease: Towards an evidence base for treatment in the 21st century. Curr Neurol Neurosci Rep. 2012;12(3):318-324.
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