DOES MY PATIENT
HAVE THYROID EYE
DISEASE (TED)?

Identify TED sooner by looking
for these signs and symptoms
SIGNS & SYMPTOMS OF TED

Image representing a specialist talking to his patient about her Thyroid Eye Disease diagnosisIImage representing a specialist talking to his patient about her Thyroid Eye Disease diagnosis

TED can be mistaken for other eye-related conditions such as allergies, conjunctivitis, or dry eye disease (DED). As the disease progresses, patients may notice additional symptoms, that can create an ever-increasing burden of disease. Not all signs and symptoms are visible, so it’s crucial to ask patients if they have had or are experiencing any TED symptoms.1,2

Signs and symptoms of TED include3-5:

  • Proptosis

  • Eyelid retraction

  • Redness, swelling, and excessive
    tearing

  • Inflammation of the caruncle or plica

  • Eyelid erythema

  • Chemosis

  • Spontaneous orbital pain

  • Dry eyes and grittiness

  • Photophobia

  • Diplopia

  • Pressure and/or pain behind the eyes

  • Foreign body sensation, or the feeling of something stuck in the eye

  • Color vision loss*

  • Vision loss*

*Affects a small subset of TED patients.

Every patient with Graves’ disease should be screened for TED

Patients with Graves’ disease have a much higher risk of developing TED. That’s why, according to the American and European Thyroid Associations’ consensus statement, all Graves’ disease patients should be screened for TED at every specialist visit.6,7

If you have a patient with Graves’ disease, refer them to a TED Specialist for a comprehensive eye exam. Find a TED Specialist >

DOWNLOAD A USEFUL CHECKLIST TO HELP IDENTIFY THE SIGNS AND SYMPTOMS OF TED AND WHEN YOUR PATIENT SHOULD CONSULT WITH A TED SPECIALIST.

DIAGNOSING TED

Early consultation with a TED Specialist can help confirm a TED diagnosis

TED is a heterogeneous condition, meaning symptoms may vary from patient to patient. Since TED manifestations can appear similar to other conditions, partnering with a TED Specialist can help make an accurate diagnosis. Refer your patients to a TED Specialist to conduct a comprehensive TED eye exam. This could include a visual field test, a slit lamp exam, a Snellen test, and a proptosis measurement with a exophthalmometer.1,3,4,7,8

For further confirmation, a CT scan or MRI of the eye muscles may be helpful. These scans can show swelling and enlargement of tissue in and around the orbit, which can be early signs of TED.9,10

MRI, magnetic resonance imaging.

Assessing TED activity with the Clinical Activity Score (CAS) and clinical classification tools

CAS is one of several assessment scales designed to evaluate the signs and symptoms characteristic of inflammatory TED. CAS is typically used in clinical trials and by payors. If used as a marker of disease activity, CAS can be effective for determining whether anti-inflammatory therapy could be prescribed. However, CAS does not account for severity of TED.4,6

In addition to CAS, other clinical classification tools have been used to diagnose TED. The NOSPECS classification synthesizes symptoms of TED into 1 of 7 categories: No physical signs or symptoms, Only signs, Soft tissue involvement, Proptosis, Extraocular muscle signs, Corneal involvement, and Sight loss. Due to its focus on severity alone, the NOSPECS assessment is no longer widely used and has been replaced by other scales, such as the VISA Classification, which grades by both disease severity and activity. VISA organizes clinical features of TED into the following categories: Vision, Inflammation, Strabismus, and Appearance.9

TED is a lifelong and progressive autoimmune disease, so disease manifestation can differ regardless of a patient's disease activity.3,5,11-13 When evaluating a patient for TED, it is important to include an assessment of emotional well-being and activities of daily living in addition to the clinical signs and symptoms to understand the overall burden of TED.

For more information on when to consult with a TED Specialist, reference this guide.

TED IS A COMPLEX DISEASE AND IS RECOMMENDED TO BE CO-MANAGED BY A MULTIDISCIPLINARY TEAM.7

Partner with a TED Specialist to help create a seamless experience throughout your patient’s treatment journey.

TED TREATMENT

TED treatment options

Early Thyroid Eye Disease treatment can help prevent serious eye damage.4,12 TED treatment options include:

  • Topical treatments (eg, lubricating eye drops and gels): over-the-counter eye drops or gels may provide relief for some symptoms of TED including dry, gritty eyes or for easing eyelid retraction5
  • Orbital radiotherapy: involves low-dose radiation delivered to and around the eyes to decrease inflammation caused by TED14-16
  • Glucocorticoids (steroids): prescribed to address inflammation caused by TED11
  • Surgical procedures (ie, orbital and bony decompression surgery): surgeries often performed by oculoplastic surgeons or strabismus surgeons are performed to address damage caused by scarring. Multiple surgeries are often needed to correct the issues caused by TED, including eyelid retraction or misalignment17,18
  • FDA-approved treatment for TED

Click here for more information about a treatment option for TED

Next page > How to Co-manage TED

  1. Couch SM. Thyroid Eye Disease: timely diagnosis is key to controlling this autoimmune condition. Glaucoma Today. January/February 2019. Accessed January 20, 2023. https://assets.bmctoday.net/glaucomatoday/pdfs/0119GT_F2_Couch.pdf
  2. Cockerham KP, Padnick-Silver L, Stuertz N, Francis-Sedlak L, Holt RJ. Quality of life in patients with chronic Thyroid Eye Disease in the United States. Ophthalmol Ther. 2021;10:975-987.
  3. Bahn RS. Graves’ ophthalmopathy. N Engl J Med. 2010;362(8):726-738.
  4. 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.
  5. Bothun ED, Scheurer RA, Harrison AR, Lee MS. Update on Thyroid Eye Disease and management. Clin Ophthalmol. 2009;3:543-551.
  6. Jain AP, Jaru-Ampornpan P, Douglas RS. Thyroid Eye Disease: redefining its management—a review. Clin Exp Ophthalmol. 2021;49(1):203-211.
  7. Burch HB, Perros P, Bednarczuk T, et al. Management of Thyroid Eye Disease: a consensus statement by the American Thyroid Association and the European Thyroid Association. Thyroid. 2022;32(12):1-32.
  8. Liaboe CA, Clark TJ, Simmons BA, Carter K, Shriver EM. Thyroid Eye Disease: an introductory tutorial and overview of disease. April 23, 2020. Accessed on January 24, 2023. https://eyerounds.org/tutorials/thyroid-eye-disease/index.htm
  9. Dolman PJ. Grading severity and activity in Thyroid Eye Disease. Ophthalmic Plast Reconstr Surg. 2018;34(4S suppl 1):S34-S40.
  10. Kilicarslan R, Alkan A, Ilhan MM, Yetis H, Aralasmak A, Tasan E. 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.
  11. Patel A, Yang H, Douglas RS. A new era in the treatment of Thyroid Eye Disease. Am J Ophthalmol. 2019;208:281-288.
  12. Wang Y, Patel A, Douglas RS. Thyroid Eye Disease: how a novel therapy may change the treatment paradigm. Ther Clin Risk Manag. 2019;15:1305-1318.
  13. Dik WA, Virakul S, van Steensel L. Current perspectives on the role of orbital fibroblasts in the pathogenesis of graves’ ophthalmopathy. Exp Eye Res. 2016;142:83-91.
  14. Bradley EA, Gower EW, Bradley DJ, Meyer DR, Cahill KV, Custer PL, Holck DE, Woog JJ. Orbital radiation for graves ophthalmopathy: a report by the American Academy of Ophthalmology. Ophthalmol. 2008;115(2):398-409.
  15. Liaboe CA, Simmons BA, Clark TJ, Shriver EM. Thyroid Eye Disease: a summary of information for patients. January 17, 2020. Accessed June 8, 2022. https://eyerounds.org/patients/thyroid-eye-disease.htm
  16. Kazim M, Garrity JA. Orbital radiation therapy for Thyroid Eye Disease. J Neuroophthalmol. 2012;32(2):172-6.
  17. Naik MN, Nair AG, Gupta A, Kamal S. Minimally invasive surgery for Thyroid Eye Disease. Indian J Ophthalmol. 2015;63(11):847-853.
  18. Boyd K, McKinney JK. Ophthalmology Subspecialists. Feb 24, 2023. Accessed September, 24, 2023. https://www.aao.org/eye-health/tips-prevention/ophthalmology-subspecialists