When Are Dry, Irritated Eyes a Sign of Thyroid Eye Disease?

What are the stages of TED?

There are two phases to the disease:

• The active (inflammatory) phase lasts between six months and three years. This is when the majority of symptoms manifest.
• The inactive (chronic) phase is the final stage, when the active inflammation quiets down yet the formation of fibrous connective tissue around damaged and inflamed parts of the eye can lead to new or worsening vision problems.

Common symptoms of TED

Symptoms in the active phase can range from mild to severe, but only a very small percentage of people will experience TED that threatens their sight. 

In the first stage of the disease, eyes appear red and swollen. They might feel dry, itchy and irritated (imagine getting a bit of sand in your eyes). The eyelids are often retracted, meaning the upper lid is too high and you can see the white of the eye above the cornea, which gives people a slightly startled appearance. “Because more of the white is exposed, the conjunctiva [the clear mucous membrane that covers the surface of the eyeball] gets dry,” Pearce says. 

This can lead to lots of tearing, which can blur vision, as well as sensitivity to light. What’s more, says Jules Winokur, M.D., vice chair of ophthalmology at New York City’s Manhattan Eye, Ear & Throat Hospital, “a retracted lid can lead to a lower blink rate. And if you don’t blink, tears aren’t being spread around the surface of the eye.” 

If TED is left untreated, inflammation can get worse. Progressive swelling may cause increased pressure and pain in the back of the eye socket, which worsens with eye movements. The eye muscles can also tighten and hinder eye movement, possibly leading to double vision.

Worse still, TED can even cause secondary glaucoma. “If the swelling from the buildup of tissues in the eye socket is bad enough, the pressure can cause compression of the optic nerve, resulting in progression of vision loss,” says Matthew Zhang, M.D., an oculoplastic surgeon at Seattle’s Eye Institute at Harborview and an associate professor of ophthalmology at the University of Washington.

Symptoms in the second and final stage of the disease include protuberance or bulging of the eye, since the muscles and soft tissues behind the eyeball swell, pushing the eye forward. “The disease will burn itself out. But often patients will be left with some degree of protrusion of the eye, eyelid retraction or double vision that requires medical attention,” Zhang explains. 

Quality-of-life issues 

Not all the challenges of thyroid eye disease are physical. According to a survey of physicians treating TED, patients find it difficult to function in social situations, with about a third experiencing anxiety and/or depression. Problems with the alignment of the eyes and double vision, in particular, can affect the quality of life.

“Double vision can knock you out of commission — you can’t drive or do normal activities,” Winokur says. “And there are people who are in constant pain from dry eye. They use eye drops and get relief for five minutes, then go on the computer and can’t work.” 

Fortunately, help is available. The Graves’ Disease and Thyroid Foundation offers resources and online support groups for those suffering with thyroid eye disease, including at onegravesvoice.com. 

Easing eye discomfort 

A doctor who suspects you have Graves’ eye disease will first examine your thyroid for abnormalities. If an overactive thyroid is the cause, your doctor will make sure it’s controlled with antithyroid medications. Graves’ disease and thyroid eye disease share a similar biology — both are caused by the immune system’s attack on healthy tissue — yet one doesn’t necessarily cause the other. TED can occur when thyroid levels are high, normal or low.

For those with mild TED, slipping on a pair of sunglasses may help with light sensitivity. Adding prisms to your glasses may do away with double vision, too. Irritation can be managed with cool compresses, artificial tears and an eye gel at night. “If the eye is pushed forward and more prominent, you can’t close your lid properly when you’re asleep,” Pearce says. “A lubricating gel can protect the surface of the eye.” 

Be wary of over-the-counter eye drops — the FDA has recalled dozens of brands in stores and on Amazon for the risk of temporary or permanent vision problems. (If you can’t get prescription eye drops, read “How to Find Safe Eye Drops Amid FDA Warnings” before making a purchase.) The FDA’s website also regularly posts recall notices.

And if you’re a smoker, consider this one more reason to stop: Smokers with Graves’ disease are about twice as likely to develop TED as those who don’t smoke, and smoking makes TED worse.

Gut health and TED

Multiple studies have shown that gut dysfunction could fuel Graves’ disease and TED. Many studies, including one published in the Journal of Clinical Endocrinology and Metabolism, have shown an imbalance in two key types of gut bacteria that could contribute to the development of the disease. This supports decades of research that suggests gut dysfunction is a “leg” that helps prop up the “stool” (or “triad”) of autoimmunity.

Whether prebiotics or probiotics might correct this imbalance and help decrease TED needs more research, but at least one large analysis showed a modest effect on reducing the antibody thought to be responsible for TED. 

However, adding specific foods to your diet may also help to improve gut health. Some are foods rich in galactooligosaccharides (GOS; a type of prebiotic often found in foods with lactose) and fiber, which could help strengthen the gut. 

To get more GOS in your diet, try these healthy alternatives to full-fat milk and butter: 

• Lentils
• Greek yogurt
• Kefir
• Chickpeas 

To get more fiber in your diet, try these nutrient-dense foods: 

• Raspberries
• Green peas
• Quiona (cooked)
• Split peas 

For even more tips to boost your fiber intake, read “8 Ways to Get More Fiber in Your Diet.” 

Selenium, a mineral mainly found in grains and nuts, may also be helpful. “If a patient’s diet is poor in selenium, we may recommend that they eat Brazil nuts, which have a high amount of selenium,” Pearce says. “It’s also an antioxidant, so it helps with inflammation in the eyes. Or we may give them a mineral supplement with selenium in it.”

Nonsurgical treatments 

Corticosteroids. For more aggressive symptoms, your doctor may suggest corticosteroids (particularly prednisone) to reduce inflammation. “Eyes that are inflamed — lots of redness, watering and tearing, swelling of the eyelids or the whites of the eye, and grittiness — can be treated very nicely with steroids,” Pearce says. 

Tepezza. Another option is Tepezza, FDA approved in 2020 as the first prescription medication to treat TED. It’s given via an IV in your arm every three weeks for a total of eight times. Tepezza stops the growth of the muscles and soft tissue behind the eye to reduce eye bulging, double vision and pain. It’s promising, for sure, but you’ll want to talk to your doctor.

For one thing, there may be side effects. (Recently, more than half the participants of a small study experienced hearing loss to varying degrees after being treated.) And there’s the jaw-dropping price tag: Tepezza is estimated to cost at least $17,929 for one vial. Insurance coverage and patient out-of-pocket costs vary, depending on insurance plans.

Surgical treatments 

Ultimately, even after TED is under control, people may need rehabilitative surgery to correct the appearance of their eyes and return them to their previous shape. 

Orbital decompression surgery. Performed when pressure on the optic nerve is threatening vision. An endoscope is carefully maneuvered through the nose and the sinus near the eyes, and pieces of bone and tissue are removed to give the eye more room to fall back into place. “It also reduces some of the compression around the optic nerve,” says Winokur. A pair of outpatient procedures, performed using local anesthesia, can tackle other problems. 

Eye muscle surgery. Performed when scar tissue, which forms around eye muscles, becomes stiff, causing eyes to become misaligned and leading to double vision. A surgeon repositions the muscles, bringing eyes into alignment. 

Eyelid repositioning surgery. Performed when the muscles of the eyelids are too tight, causing the eyelids to open too widely. Eyelid muscles or tendons are released, allowing the eyelid to return to a more natural position. 

Even after corrective surgeries are completed, you may be left with some unwelcome souvenirs “because your eyelids swell up with inflammation and fluid, and because you probably rub them a lot,” says Pearce. “That stretches the skin. People are often left with saggy, baggy eyes.” 

Swollen and puffy tissue around the eye can be tightened with blepharoplasty (more commonly known as an eye lift). Laser resurfacing and injections, such as Restylane, can give saggy skin a boost.