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
Do you see changes to the tissues around the eye? Eyelid retraction or edema? Exophthalmos?7
Have signs or symptoms worsened recently? Do they vary over the course of the day?7
Does the patient report grittiness? Tearing? Pain or pressure around or behind the eyes?7
Do you see erythema or redness of the eye? Oozing and swelling around the conjuctiva (chemosis)?7
Is the patient experiencing photophobia, diplopia, or changes in visual acuity, visual fields, or color vision?7
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
- Spontaneous orbital pain
- Gaze-evoked orbital pain
- Eyelid swelling that is considered to be due to Active TED
- Eyelid erythema
- Conjunctival redness that is considered to be due to Active TED
- Inflammation of the caruncle or plica
This site is dedicated to advancing the understanding of thyroid eye disease.
Find useful information and resources on the signs, impact, risks, and mechanisms
of thyroid eye disease to support you in your conversations with patients and caregivers.
Sign up for updates
Stay connected with the latest science
and available resources
- 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.
- Laurberg P, Berman DC, Pedersen IB, Andersen S, Carlé A. J Clin Endocrinol Metab. 2012;92(7):2325-2332.
- 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.
- 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.
- Barrio-Barrio J, Sabater AL, Bonet-Farriol E, Velázquez-Villoria Á, Galofré JC. Graves' ophthalmopathy: VISA versus EUGOGO classification, assessment, and management. J Ophthalmol. 2015;2015:249125.
- 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.
- Bruscolini A, Sacchetti M, La Cava M, et al. Quality of life and neuropsychiatric disorders in patients with Graves' orbitopathy: current concepts. Autoimmun Rev. 2018;17:639-643.
- Vardizer Y, Berendschot TTJM, Mourits MP. Effect of exophthalmometer design on its accuracy. Ophthal Plast Reconstr Surg. 2005;21(6):427-430.
- Maheshwari R, Weis E. Thyroid associated orbitopathy. Indian J Ophthal. 2011;60(2):88-93.
- Dolman PH. Grading severity and activity in thyroid eye disease. Ophthal Plast Reconstr Surg. 2018;34:S34-S40.
- Bartley GB, Fatourechi V, Kadrmas EF, et al. Long-term follow-up of Graves ophthalmopathy in an incidence cohort. Ophthalmology. 1996;103:958-962.
- Mitchell AL, Goss L, Mathiopoulou L, et al. Diagnosis of Graves' orbitopathy (DiaGO): Results of a pilot study to assess the utility of an office tool for practicing endocrinologists. J Clin Endocrinol Metab. 2015;100(3):E458-E462.
- Ponto KA, Pitz S, Pfeiffer N, Hommel G, Weber MM, Kahaly GJ. Quality of life and occupational disability in endocrine orbitopathy. Dtsch Arztebl Int. 2009;106:283-299.
- 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.
- Kahaly GJ, Petrak F, Hardt J, Pitz S, Egle UT. Psychosocial morbidity of Graves’ orbitopathy. Clin Endocrinol. 2005;63:395-402.
- Yang DD, Gonzalez MO, Durairaj VD. Medical management of thyroid eye disease. Saudi J Ophthalmol. 2011;25:3-13.
- Strianese D, Iuliano A, Ferrara M, et al. Methotrexate for the treatment of thyroid eye disease. J Ophthalmol. 2014;2014:128903.
- 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.
- Phelps P, Williams K. Thyroid eye disease for the primary care physician. Disease-a-Month. 2014;60:292-298.