Thyroid eye disease (TED) is an autoimmune condition that affects the tissues around the eyes. It is most commonly associated with Graves’ disease, but TED can also occur in people whose thyroid is functioning normally or is underactive.
That is one of the most confusing things about TED:
You can have thyroid eye disease with a high thyroid, a low thyroid, or a normal thyroid.
Thyroid eye disease is related to inflammation and enlargement of the tissues inside the eye socket (orbit) including the eye muscles and surrounding orbital fat. The amount of thyroid hormone in your blood does not always tell us how active or severe the eye disease is.
How Is Thyroid Eye Disease Diagnosed?
TED is primarily a clinical diagnosis, meaning your doctor looks carefully at your symptoms and the physical signs affecting your eyes.
The evaluation may include checking:
- Eye movement and whether the muscles are restricted
- The position of the eyes and degree of proptosis (eye bulging or exophthalmos)
- Eyelid position, including eyelid retraction (both upper lid and lower lid)
- Eye redness and swelling
- Vision and color vision with changes
- Eye pressure elevation
- The health of the optic nerve
Thyroid blood tests and thyroid antibodies can provide additional information, but thyroid levels alone do not diagnose or rule out TED. Imaging such as CT or MRI may also be helpful when the diagnosis is uncertain, when the optic nerve needs to be evaluated, or when surgery is being planned.
What Does Thyroid Eye Disease Feel Like?
Some of the symptoms of TED can be easy to dismiss at first.
You may experience:
- Pain or pressure behind the eyes
- Pain with eye movement
- Blurry vision
- Dryness or a gritty feeling
- Light sensitivity
- Excess tearing
- Double vision
These symptoms can happen because the tissues surrounding the eyes become inflamed and swollen.
What Changes Can Thyroid Eye Disease Cause?
TED can produce visible changes in and around the eyes.
Proptosis (exophthalmos)
The eyes may appear to bulge or move forward because the muscles and/or fatty tissue inside the eye socket become enlarged.
Restricted eye movement
When the eye muscles become swollen and eventually scar or stiffen, the eyes may not move normally. This can cause diplopia, or double vision.
Redness and swelling
The eyelids and the tissues covering the eye may become red, swollen, or irritated.
Eyelid retraction
The muscles and tissues of the upper and lower eyelids can tighten and scar, pulling the eyelids farther open. This can expose more of the white part of the eye, the sclera that normally is not visible.
Elevated eye pressure
Changes in the tissues around the eye can contribute to increased eye pressure. In some patients, elevated pressure can cause damage to the optic nerve, which is essential for vision.
In more serious cases, the optic nerve can become compressed, or the cornea can become damaged because the eyelids cannot fully protect the eye. Changes in color vision or loss of part of the visual field require prompt evaluation.
Can You Have TED Even If Your Thyroid Levels Are Normal?
This is an important point.
Approximately 90% of TED cases are associated with hyperthyroidism (most commonly Graves’ disease). However, about 10% of individuals have normal or under-functioning thyroid levels (such as Hashimoto’s thyroiditis). The development and severity of TED depend on hypertrophy (enlargement) of your eye muscles and surrounding orbital fat, which does not always directly correlate with circulating thyroid hormone levels.
How Is Thyroid Eye Disease Treated?
Treatment depends on how active and severe the disease is, what symptoms are present, and whether vision is at risk.
1. Treat the Thyroid Disease
Keeping thyroid function appropriately controlled is an important part of care. Your endocrinologist or thyroid specialist will manage the underlying thyroid condition, while your ophthalmologist evaluates and treats the eye disease.
Because TED can involve both the thyroid and the eyes, coordinated care between your endocrinologist and eye doctor is important.
2. Lifestyle Medicine
Lifestyle factors also matter.
Smoking is one of the most important modifiable risk factors for TED. Smoking can increase the risk of developing TED and is associated with worsening disease and reduced treatment effectiveness. In fact, smoking almost doubles the rate of development, progression and severity of TED but the effect is reversible if smoking stopped.
Other supportive measures may include maintaining appropriate thyroid levels, addressing nutritional needs, managing stress, and protecting the eyes from dryness and environmental irritation.
There was a study in 2025 that showed that a Mediterranean diet high in selenium (found in legumes, cereals, eggs, nuts, fish) can help decrease inflammation and help spontaneous resolution in >70% of mild Graves Orbitopathy or Thyroid Eye Disease.
You can also have your doctor check for selenium deficiency as supplementation can also help mild thyroid disease and it is a recommended treatment in mild TED by American Thyroid Association and European Thyroid Association with 61% of supplemented pts improved vs. 36% with placebo and there was more disease progression in placebo group (26% vs.7% in selenium group).
3. Medications
For appropriate patients, targeted medications can help treat TED.
Tepezza® (teprotumumab) was the first FDA-approved medication (in 2020) for thyroid eye disease. It targets the IGF-1 receptor, a pathway involved in the disease process. It helped 83% of patients with proptosis and 68% with double vision compared to 10% with placebo.
Tepezza can cause side effects including muscle spasms (25%), nausea, diarrhea, fatigue, elevated blood sugar, and hearing impairment (10-22%). Hearing changes can sometimes be severe or permanent, so hearing should be assessed and monitored before and during treatment.
Lumvoa® (veligrotug-vvze) is another IGF-1 receptor inhibitor. The FDA approved Lumvoa in June 2026 for the treatment of TED regardless of disease activity or duration. It helped 70% of patients with proptosis and 59% with double vision compared to 5% with placebo.
Common adverse reactions reported with Lumvoa include muscle spasms (40%), headache, hearing impairment (15%), elevated blood sugar, fatigue, diarrhea, ear discomfort, infusion reactions, nausea, dry skin, and high blood pressure. Its prescribing information also includes warnings regarding inflammatory bowel disease, hyperglycemia, and hearing impairment.
Your doctor will determine whether these treatments are appropriate based on your individual condition.
4. Lowering Eye Pressure
If TED is associated with elevated eye pressure, eye drops or other treatments may be used to lower the pressure and protect the optic nerve.
5. Helping Double Vision
If TED causes mild and stable double vision, prisms in your glasses may help align the images seen by each eye and make everyday activities more comfortable. For variable or moderate to severe double vision, you may need more active therapies like those mentioned above.
Comorbid Condition
Did you know that about 15-18% of patients with myasthenia gravis also have thyroid disease (although the reverse is smaller – only 0.2% of those with thyroid disease have myasthenia gravis)? Myasthenia gravis can also be a cause of variable double vision. It is autoimmune disorder that attacks muscles. It can be the cause of the double vision and droopy eyelids especially with fatigue or at the end of the day. Both conditions are important to evaluate if you are having double vision symptoms.
What About Surgery?
Surgery may be considered when TED has become inactive or quiet, meaning the disease has stabilized.
For significant proptosis, orbital decompression surgery can create more space inside the eye socket by removing selected portions of the orbital bone and, in some cases, orbital fat. This can help move the eyes back and create additional space for enlarged muscles and the optic nerve.
If restrictive eye muscles are causing persistent double vision, eye muscle surgery may be performed to improve eye alignment.
Surgery is generally planned in stages when multiple procedures are needed, with orbital decompression typically performed before strabismus surgery. Surgery may be needed sooner when vision is threatened.
Protect Your Vision Healthspan
Thyroid eye disease can affect much more than appearance. It can affect comfort, eye movement, vision, and quality of life and in severe cases, vision itself can be at risk.
Early recognition and coordinated care can make a difference.
If you have thyroid disease and are experiencing eye pain, pressure, blurry or double vision, eye bulging, redness, swelling, or changes in your eyelids, don’t ignore the symptoms.
Call Eye Doctor MD, PC at (804) 270-3333 to schedule a consultation with Dr. Pradhan.
Dr. Pradhan can evaluate your eyes, monitor your vision and eye pressure, and help determine whether additional treatment or coordination with your endocrinologist is needed.
Schedule a consultation with Dr. Pradhan to support your Vision Healthspan and your whole-body health.
And if you know a family member or friend living with thyroid disease who may benefit from this information, please share this article with them.
Your eyes are part of your whole-body health. Taking care of both can help you see and live your best.
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Sources:
https://eyewiki.org/Thyroid_Eye_Disease
https://pmc.ncbi.nlm.nih.gov/articles/PMC9462910
https://www.tepezza.com/about-tepezza/tepezza-side-effects-and-safety
Dr. Shilpi Pradhan is a board-certified ophthalmologist, cornea specialist, and founder of Eye Doctor MD PC. Beyond providing advanced clinical treatments for dry eye disease, she guides patients in adopting targeted lifestyle changes to improve both their eye health and overall whole-body wellness. As one of the first Virginia ophthalmologists board-certified in Lifestyle Medicine (2020) and a member of the American College of Lifestyle Medicine (ACLM), Dr. Pradhan combines modern ocular care with evidence-based nutrition and habit changes to support long-term Vision Healthspan.