AKT · Ophthalmology/Orbit & infection

Thyroid eye disease (Graves orbitopathy)

Autoimmune orbital inflammation associated with Graves disease

Overview

Autoimmune inflammation and expansion of the orbital fat and extraocular muscles associated with Graves disease (can occur euthyroid/hypothyroid). Causes proptosis, lid retraction, restrictive diplopia and ocular-surface exposure; the sight-threatening complication is compressive (dysthyroid) optic neuropathy. Smoking markedly worsens it. Managed with risk-factor control, selenium, steroids/immunotherapy and orbital decompression.

Recognise

Bilateral (often asymmetric) proptosis (exophthalmos), LID RETRACTION and lid lag, grittiness and watering
Restrictive DIPLOPIA from enlarged muscles (inferior/medial rectus); conjunctival injection over the muscle insertions; exposure keratopathy
Features of Graves (goitre, tremor, weight loss, AF); smoking is a major risk factor

Red flags

Reduced colour vision, an RAPD, or reduced acuity → compressive (dysthyroid) OPTIC NEUROPATHY — urgent (sight-threatening)
Corneal exposure/ulcer from severe proptosis → urgent corneal protection

Differentials & how to tell them apart

Orbital cellulitisacute, febrile, unilateral, with pain on movement — TED is subacute and afebrile

Orbital pseudotumour/myositispainful, usually unilateral idiopathic inflammation; muscle tendons involved on imaging

Orbital tumour/lymphomaprogressive unilateral proptosis with a mass on imaging

Carotid-cavernous fistulapulsatile proptosis, bruit, dilated 'corkscrew' conjunctival vessels

Thyroid eye disease — MRI showing enlarged extraocular muscles
Huy A Tran & Glenn EM Reeves / CC BY-SA 4.0 — Wikimedia Commons

Investigations

Thyroid function + TSH-receptor antibodies; assess proptosis (exophthalmometry), eye movements, colour vision, acuity, pupils; CT/MRI orbits (muscle enlargement sparing tendons); visual fields if optic neuropathy suspected.

Management

Stop smoking + restore euthyroidism + lubricants; immunosuppression/decompression for active/sight-threatening disease

1Restore and maintain euthyroidism, STOP smoking, ocular lubricants for exposure, selenium for mild active disease. Refer to a TED/orbital service for grading.Gate: Reduced colour vision, RAPD or reduced acuity = compressive OPTIC NEUROPATHY → urgent high-dose steroids ± orbital DECOMPRESSION (sight-threatening), not routine management
2Moderate-to-severe active disease → IV methylprednisolone ± mycophenolate/teprotumumab/orbital radiotherapy; rehabilitative surgery (decompression → squint → lid) once inactive.

Smoking cessation + restore euthyroidism — the most important modifiable factors

Selenium / ocular lubricants — mild disease and surface protection

IV methylprednisolone (± mycophenolate) / teprotumumab / orbital radiotherapy — moderate-to-severe active disease — specialist

Orbital decompression surgery — for compressive optic neuropathy or disfiguring proptosis

Key points

Proptosis + lid retraction + restrictive diplopia + Graves = thyroid eye disease; smoking is the worst accelerant. The emergency is dysthyroid optic neuropathy — colour vision and the RAPD are the warning signs. (Graves is a content-map Endocrine item — cross-referenced here for the orbital disease.)

Monitor & prognosis

Disease activity (CAS), colour vision/acuity; thyroid status; smoking.

Burns out over 1–3 years; residual proptosis/diplopia may need surgery.

Source: RCOphth/British Thyroid Association TED guidance; EUGOGO