Thyroid eye disease
At a glance
Autoimmune orbital disease. Assess activity and severity separately; sight-threatening disease needs urgent treatment.
CAVE
- Reduced colour vision, an afferent pupillary defect, visual loss or corneal breakdown can signal sight-threatening disease.
Clinical presentation
- Lid retraction, proptosis, irritation, orbital discomfort and restrictive diplopia.
Diagnosis & investigations
- Measure acuity, colour vision, RAPD, fields when indicated, proptosis, lid aperture/closure, corneal exposure, motility and diplopia. Compare serial measurements with the same method. Orbital imaging is useful for atypical/asymmetric disease, suspected apical compression or surgical planning.
- At first assessment the 7-item CAS assigns one point each for spontaneous retrobulbar pain, pain on gaze, eyelid redness, conjunctival redness, eyelid swelling, caruncle/plica swelling and chemosis; ≥3/7 supports activity. Severity is assessed separately by functional impact, diplopia, proptosis, exposure and optic nerve compromise.
Differential diagnosis
- Orbital inflammation, tumour, vascular disease, myasthenia and other causes of restrictive strabismus.
Treatment
- Coordinate endocrinology and ophthalmology, stop smoking and maintain euthyroidism. Choose treatment by activity, severity and patient priorities, not CAS alone. Discuss glucocorticoid-based regimens, other immunomodulation or teprotumumab in an experienced service; local access and safety profile influence selection.
- Suspected dysthyroid optic neuropathy is an emergency even without marked proptosis. Reduced colour vision, RAPD or new field loss requires same-day escalation. Exposure with epithelial breakdown needs immediate surface protection and possible surgical measures.
| Finding | Action | Timing / detail |
|---|---|---|
| Mild disease without sight threat | Lubrication, exposure protection, smoking cessation and stable thyroid function; selected selenium supplementation in selenium-deficient settings | Monitor function and progression; activity alone does not define severity |
| Active moderate-to-severe disease impairing daily life | Refer to a combined thyroid-eye service for immunomodulatory treatment; IV glucocorticoid-based therapy remains an established option | Evaluate hepatic, cardiovascular, infectious, glucose and psychiatric risks before systemic treatment |
| Dysthyroid optic neuropathy or corneal breakdown | Same-day specialist emergency management: IV glucocorticoids for DON, with urgent decompression for insufficient response; protect/treat the cornea | Do not wait for a high CAS, marked proptosis or routine thyroid appointment |
| Teprotumumab for adults with moderate-to-severe TED | EU authorised since 19 June 2025; specialist selection with hearing, glucose and inflammatory bowel disease assessment | 8 IV infusions every 3 weeks; contraindicated in pregnancy. EU authorisation does not ensure local reimbursement |
| Inactive, stable residual disease | Plan rehabilitation according to need: orbital decompression, then strabismus surgery, then eyelid surgery | Confirm stability; prisms may help selected diplopia while awaiting definitive treatment |
Follow-up
- Active or changing disease needs review over weeks, with acuity, colour, cornea and motility repeated; stable mild disease can be spaced further apart. During systemic therapy use the product/regimen-specific laboratory and safety schedule. With teprotumumab, assess hearing before, during and after treatment and monitor glucose; new hearing or bowel symptoms require prompt review.
Risk factors & context
- Smoking and unstable thyroid function increase concern for deterioration.
- Assess activity separately from the degree of proptosis.
Complications
- Compressive optic neuropathy, exposure keratopathy and persistent diplopia.
- Marked proptosis is not required for sight-threatening optic nerve compression.
When to refer
- Immediate specialist assessment for suspected dysthyroid optic neuropathy or severe corneal exposure.
References 2
- EUGOGO · Clinical practice guidelines for Graves’ orbitopathy ↗2021 · Table 1; activity and severity; sight-threatening disease
- EMA · Tepezza (teprotumumab) ↗EU authorisation 19 June 2025 · product information updated 25 March 2026 · Indication; infusion schedule; hearing, glucose, bowel and pregnancy precautions
European guidance. Drug availability and authorisations must be checked locally.