Thyroid eye disease affects between 25-50% of patients with Graves' disease.


  • Incidence: 10.00 cases per 100,000 person-years
  • Peak incidence: 30-40 years
  • Sex ratio: more common in females 6:1
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+


  • smoking is the most important modifiable risk factor for the development of thyroid eye disease
  • radioiodine treatment may increase the inflammatory symptoms seen in thyroid eye disease. In a recent study of patients with Graves' disease around 15% developed, or had worsening of, eye disease. Prednisolone may help reduce the risk


  • it is thought to be caused by an autoimmune response against an autoantigen, possibly the TSH receptor → retro-orbital inflammation
  • the inflammation results in glycosaminoglycan and collagen deposition in the muscles

Clinical features

  • the patient may be eu-, hypo- or hyperthyroid at the time of presentation
  • exophthalmos
  • conjunctival oedema
  • optic disc swelling
  • ophthalmoplegia
  • inability to close the eyelids may lead to sore, dry eyes. If severe and untreated patients can be at risk of exposure keratopathy


  • topical lubricants may be needed to help prevent corneal inflammation caused by exposure
  • steroids
  • radiotherapy
  • surgery

Monitoring patients with established thyroid eye disease

For patients with established thyroid eye disease the following symptoms/signs should indicate the need for urgent review by an ophthalmologist (see EUGOGO guidelines):
  • unexplained deterioration in vision
  • awareness of change in intensity or quality of colour vision in one or both eyes
  • history of eye suddenly 'popping out' (globe subluxation)
  • obvious corneal opacity
  • cornea still visible when the eyelids are closed
  • disc swelling