SIGNS & SYMPTOMS OF TED

Thyroid Eye Disease (TED) is progressive, and early intervention can reduce disease impact1,2

Signs and symptoms of TED may include1-3

Artistic rendering of proptosis, a common symptom of Thyroid Eye Disease

Proptosis

Proptosis is caused by the expansion of the orbital fat and muscles behind the eyes. The lacrimal glands are frequently involved and enlarged, causing bulging of the eye. Proptosis is one of the most common symptoms of TED.1

Artistic rendering of diplopia, or double vision, a common Thyroid Eye Disease symptom

Diplopia

Diplopia is caused by swelling and inflammation of the extraocular muscles and typically restricts the movement of the eye, causing double vision. The most frequently involved muscle is the inferior rectus.4

Artistic rendering of eyelid retraction, a common symptom of Thyroid Eye Disease

Eyelid
retraction

Upper eyelid retraction is one of the most common symptoms of TED. Evidence shows that up to 80% to 90% of patients with TED develop upper eyelid retraction.1,4 Retraction develops from levator and Müller muscle inflammation and fibrosis or from levator muscle overaction caused by inferior rectus restriction.1,5

Artistic rendering of pressure or pain behind the eye

Pressure and/or pain behind the eyes

TED causes an increase in the orbital soft tissue volume, which leads to a higher pressure within the inexpandable bone cavity.1

Artistic rendering of photophobia, also known as light sensitivity

Photophobia

Photophobia, or light sensitivity, often occurs in TED patients when the upper eyelid retracts, resulting in corneal exposure.5

Artistic rendering of dry, gritty eyes caused by Thyroid Eye Disease

Dry eyes and grittiness

Dry eyes and grittiness are frequently overlooked signs of TED.6 57% of TED patients in a study reported ocular dryness/grittiness.7 These symptoms are often misdiagnosed as Dry Eye Disease (DED), allergies, or conjunctivitis.8

Artistic rendering of eye redness, swelling, and excessive tearing caused by Thyroid Eye Disease

Redness, swelling, and excessive tearing

Erythema (redness) and edema (swelling) of the eyelids are common TED symptoms. Eyelid retraction combined with proptosis can lead to reflex tearing.1,4,5

Artistic rendering of the feeling of something stuck in the eye

The feeling of something stuck in the eye

Some patients may feel like a piece of dust or dirt is stuck in their eyes even though nothing is really present—a phenomenon known as “foreign body sensation.”2

Artistic rendering of color vision loss, or acquired color vision deficiency, caused by Thyroid Eye Disease

Color vision loss*

Also known as Acquired Color Vision Deficiency, losing color vision can mean that the optic nerve is being damaged and there is a risk of vision loss. Colors may not appear as bright as they once were, or there’s a difference in the brightness of colors when comparing one eye with the other. In rare cases, some patients may become color blind.2,9-11

Artistic rendering vision loss caused by Thyroid Eye Disease

Vision loss*

In some cases, patients may notice some vision loss or they can’t see at all. This occurs because TED can cause swelling behind the eye that pushes down on the optic nerve. If this happens, emergency surgery may be needed to save the patient's vision. Optic nerve damage in TED patients can lead to blindness, but it’s very rare.9,12,13

The images above are representative of each sign or symptom—however severity may differ for each patient. It is important to ask your patients if they have had or are currently experiencing any of these TED symptoms.

If you notice any changes or worsening symptoms it is important to consult with a TED Specialist quickly.1 TED is a progressive, chronic, potentially vision-threatening autoimmune disease, and co-managing can help the course of TED.1,3,14

Preview image of Thyroid Eye Disease symptoms and mechanism video

TED SYMPTOMS ARE CAUSED BY THE STIMULATION OF ORBITAL FIBROBLASTS, WHICH CAUSES INFLAMMATION BEHIND THE EYE.4

Watch a video about TED’s unique mechanism of disease (MOD), its symptoms, and the importance of early diagnosis, featuring Dr Terry Smith, professor of ophthalmology and visual sciences and professor of internal medicine.

READ TRANSCRIPT

TED is distinct from other diseases, and requires different treatment4,14-18

When examining a patient who may have TED, it can be essential to have a differential diagnosis from other associated thyroid disorders or orbital disorders that may trigger with similar symptoms.19 Here’s how Graves’ disease can be differentiated from TED.

THYROID EYE DISEASE (TED) GRAVES’ DISEASE
THYROID EYE DISEASE (TED)
AFFECTED AREAS

Front and back of the eyes

Thyroid

DISEASE MANIFESTATIONS

Ocular myositis and expansion of orbital fat

Hyperthyroidism

SYMPTOMS PRESENT
IN DISEASE
PROGRESSION
  • Proptosis
  • Diplopia
  • Eyelid retraction
  • Ophthalmalgia, including pressure and/or pain around and behind the eyes
  • Keratoconjunctivitis
  • Epiphora
  • Photophobia/light sensitivity
  • Dry eyes and grittiness
  • Redness, swelling, and excessive tearing
  • The feeling of something stuck in the eye
  • Color vision loss*
  • Vision loss*
  • Tachycardia
  • Irritability
  • Fatigue
  • Hyperhidrosis, heat sensitivity
TREATMENT
OPTIONS
  • FDA-approved treatment for TED
  • Glucocorticoids (steroids)
  • Topical treatments (ie, lubricating eye drops)
  • Surgical procedures (ie, orbital and bony decompression surgery)
  • Radioactive iodine
  • Antithyroid drugs
  • Beta blockers
  • Thyroidectomy
SPECIALISTS
REQUIRED

TED Specialist

Endocrinologist

*Affects a small subset of TED patients.

AFFECTED AREAS

Front and back of the eyes

DISEASE MANIFESTATIONS

Ocular myositis and expansion of orbital fat

SYMPTOMS PRESENT IN DISEASE PROGRESSION
  • Proptosis
  • Diplopia
  • Eyelid retraction
  • Ophthalmalgia, including pressure and/or pain around and behind the eyes
  • Keratoconjunctivitis
  • Epiphora
  • Photophobia/light sensitivity
  • Dry eyes and grittiness
  • Redness, swelling, and excessive tearing
  • The feeling of something stuck in the eye
  • Color vision loss*
  • Vision loss*
TREATMENT OPTIONS
  • FDA-approved treatment for TED
  • Glucocorticoids (steroids)
  • Topical treatments (ie, lubricating eye drops)
  • Surgical procedures (ie, orbital and bony decompression surgery)
SPECIALISTS REQUIRED

TED Specialist

AFFECTED AREAS

Thyroid

DISEASE MANIFESTATIONS

Hyperthyroidism

SYMPTOMS PRESENT IN DISEASE PROGRESSION
  • Tachycardia
  • Irritability
  • Fatigue
  • Hyperhidrosis, heat sensitivity
TREATMENT OPTIONS
  • Radioactive iodine
  • Antithyroid drugs
  • Beta blockers
  • Thyroidectomy
SPECIALISTS REQUIRED

Endocrinologist

*Affects a small subset of TED patients.

TED is a heterogeneous condition, meaning symptoms may vary from patient to patient.14

Some symptoms of TED, such as eye redness, excessive tearing, grittiness and foreign body sensation, and photophobia/light sensitivity, could be misdiagnosed as Dry Eye Disease (DED). DED results from an insufficient lubrication to the eye's aqueous tear film layer due to insufficient tear production or evaporation loss. DED is commonly addressed with treatments such as artificial tears or gels; however, more severe cases may result in surgery.20

Given the similarity in presentation, it is important for all eye care specialists to be aware of TED and to evaluate patients, especially those who may have preexisting thyroid conditions, for both. Here are some additional questions that can help determine if your patient needs to see a TED Specialist for a baseline eye exam:

  • Do you have or have you recently developed any new thyroid conditions?
  • Do you have or have you experienced any pain behind your eye?
  • Do your eyes have restriction of movement?
  • Have you experienced any blurry vision?
  • Have you experienced double vision?
  • Do you often think about your eyes?
  • Do your eyes look, work, or feel differently than they used to?
  • How has the appearance of your eyes changed (if TED is already suspected)?

Some early TED symptoms can also appear similar to symptoms for allergies and conjunctivitis. And in some cases, orbital cellulitis, myositis, or sinusitis may show similarities with TED presentations.8,19,21 An accurate diagnosis of TED may require ruling out the presence of these other diseases. It’s important to ask your patients if they are experiencing any new or worsening symptoms of TED.

TED is not a “watch and wait” disease—delaying diagnosis can potentially threaten patients’ vision. That’s why partnering with a TED Specialist for optimal disease management is critical.1-3

CONSULT WITH A TED SPECIALIST

Co-manage your patients together.3

  1. 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.
  2. Bothun ED, Scheurer RA, Harrison AR, Lee MS. Update on Thyroid Eye Disease and management. Clin Ophthalmol. 2009;3:543-551.
  3. 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.
  4. Bahn RS. Graves’ ophthalmopathy. N Engl J Med. 2010;362(8):726-738.
  5. Dolman PJ. Grading severity and activity in Thyroid Eye Disease. Ophthalmic Plast Reconstr Surg. 2018;34(4S suppl 1):S34-S40.
  6. Bartley GB, Fatourechi V, Kadrmas EF, et al. Long-term follow-up of Graves ophthalmopathy in an incidence cohort. Ophthalmology. 1996;103(6):958-962.
  7. 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.
  8. 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
  9. 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
  10. Thyroid Eye Disease (TED) fact sheet. PreventBlindness.org. Accessed June 8, 2022. https://www.preventblindness.org/thyroid-eye-disease
  11. Verity DH, Rose GE. Acute Thyroid Eye Disease (TED): principles of medical and surgical management. Eye (Lond). 2013;27(3):308–319.
  12. American Thyroid Association. Graves’ eye disease brochure. Accessed June 8, 2022. https://www.thyroid.org
  13. McAlinden C. An overview of thyroid disease. Eye Vis (Lond). 2014;1:9.
  14. 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.
  15. Smith TJ, Hegedüs L. Graves’ disease. N Engl J Med. 2016;375 (16):1552-1565.
  16. 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(7):639-643.
  17. Wiersinga WM. Graves’ disease: can it be cured? Endocrinol Metab (Seoul). 2019;34(1):29-38.
  18. Graves’ disease. Mayo Clinic. Accessed June 29, 2022. https://www.mayoclinic.org/diseases-conditions/graves-disease/symptoms-causes/syc-20356240
  19. Liaboe CA, Clark TJ, Simmons BA, Carter K, Shriver EM. Thyroid Eye Disease: an introductory tutorial and overview of disease. April 23, 2020. Accessed January 24, 2023. https://eyerounds.org/tutorials/thyroid-eye-disease/index.htm
  20. Verjee MA, Brissette AR, Starr CE. Dry eye disease: early recognition with guidance on management and treatment for primary care family physicians. Ophthalmol Ther. 2020;9(4):877-888.
  21. Estcourt S, Hickey J, Perros P, Dayan C, Vaidya B. The patient experience of services for Thyroid Eye Disease in the United Kingdom: results of a nationwide survey. Eur J Endocrinol. 2009;161(3):483-487.