Early diagnosis Diagnosing active disease

Active TED: Don’t miss the chance to make a difference

Thyroid eye disease has only been shown to respond to medical management while the disease is active and inflammation is ongoing.2 Once the disease becomes inactive, this type of intervention cannot address the damage to patient vision and appearance nor mitigate the impact on quality of life.7,12,13

When you suspect ted, diagnosis during
Active Thyroid Eye Disease
is critical


Worsening proptosis icon

Do you see changes to the tissues around the eye? Eyelid retraction or edema? Exophthalmos?7



Changing exophthalmos icon

Have signs or symptoms worsened recently? Do they vary over the course of the day?7



Orbital eye pain icon

Does the patient report grittiness? Tearing? Pain or pressure around or behind the eyes?7



Eye inflammation icon

Do you see erythema or redness of the eye? Oozing and swelling around the conjuctiva (chemosis)?7


Vision changes

Diplopia or vision change icon

Is the patient experiencing photophobia, diplopia, or changes in visual acuity, visual fields, or color vision?7



Symptoms of graves eye disease icon

The presence of these signs or symptoms and could indicate Active TED. Engage your ophthalmology or endocrinology partners to develop a management plan and ensure prompt intervention.

TED diagnostic tools

Clinical Activity Score

A number of protocols and tools are available to aid a TED diagnosis. Perhaps the best known is the Clinical Activity Score (CAS), a 7-point scale using classic signs and symptoms of inflammation to detect Active TED during physical exams. Each positive criterion on the CAS is given one point and a score of 3 or greater indicates active disease.7 The quick-reference guide above is largely based on CAS.


Exophthalmos is a common visible sign of TED. It is sometimes measured through imaging studies, but an accessible, in-office means of objective measurement is the exophthalmometer, a handheld tool. The most commonly used type is the Hertel exophthalmometer, which provides an absolute measure of distance from the orbital rim to the apex of the cornea.14 Other types, such as the Naugle and Luedde designs, allow measurement without making bilateral contact with the orbital rim.14

Accurate baseline measurement of exophthalmos is an important part of tracking the rapid changes in signs and symptoms that signal Active TED. However, Active TED can be diagnosed in the absence of exophthalmos when other signs of inflammation, such as erythema or edema, are present.7

7-point CAS scale

  1. Spontaneous orbital pain
  2. Gaze-evoked orbital pain
  3. Eyelid swelling that is considered to be due to Active TED
  4. Eyelid erythema
  5. Conjunctival redness that is considered to be due to Active TED
  6. Chemosis
  7. Inflammation of the caruncle or plica
Active thyroid eye disease monitoring schedule icon Active thyroid eye disease monitoring schedule icon

Remember these signs and symptoms when assessing for Active TED and monitor at least every 6 weeks. TED impacts quality of life, so always inquire about how its symptoms may be affecting the patient’s ability to function normally.12,13

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  2. 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.
  3. 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.
  4. Laurberg P, Berman DC, Pedersen IB, Andersen S, Carlé A. J Clin Endocrinol Metab. 2012;92(7):2325-2332.
  5. 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.
  6. Tsui S, Naik V, Hoa N, et al. Evidence for an association between thyroid-stimulating hormone and insulin-like growth factor 1 receptors: a tale of two antigens implicated in Graves’ disease. J Immunol. 2008;181:4397-4405.
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  8. 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.
  9. Smith TJ, Hegedüs L. Graves’ disease. N Engl J Med. 2016;375:1552-1665.
  10. 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.
  11. 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.
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