What Is It?
Graves' eye disease, also called Graves' ophthalmopathy, is a problem that develops in people with an overactive thyroid caused by Graves' disease. Up to one-half of people with Graves' disease develop eye symptoms. Usually the eye symptoms are mild and easily treated.
Eye problems result from the swelling of tissues, muscles and fat in the socket behind the eye. This swelling causes exophthalmos, an abnormal protrusion of the eye, commonly associated with Graves' disease. The eyelids and membranes may retract as they swell. This can lead to exposure and infection of the cornea. The cornea is the transparent, dome-shaped "window" that lies directly over the eye's pupil and iris.
In serious cases, the swelling can cause the muscles that move the eyeball to become so stiff that the eye cannot move properly. Also, the swelling can put pressure on the optic nerve, impairing vision.
Symptoms of Graves' eye disease include:
- Early symptoms — Feeling of irritation in the eyes, excessive tearing or dry eye, forward displacement of the eye, sensitivity to light and double vision
- Late symptoms — Swelling of the eye, inability to move the eye, corneal ulceration, and, rarely, loss of vision
If you already have been diagnosed with Graves' disease, a doctor may diagnose eye disease by examining your eyes and finding swelling and enlargement of the eye muscles. A computed tomography (CT) scan or magnetic resonance imaging (MRI) scan of the eye muscles may be helpful. Graves' disease usually is associated with other symptoms of overactive thyroid. However, the classic symptoms of hyperthyroidism are not always present. In fact, Graves' eye disease can occur even when the thyroid is not overactive at that time.
Graves' eye disease often improves on its own. But symptoms may persist despite treatment of the overactive thyroid gland and specific eye therapies.
Graves' disease cannot be prevented. And usually, the associated eye disease cannot be prevented. However, medical evidence now suggests that treatment of the overactive thyroid gland with radiation therapy is more likely to worsen the eye disease.
If radiation of the thyroid must be done, some studies suggest that patients with hyperthyroidism from Graves' disease who are given a corticosteroid drug (prednisone) at the same time they receive radioactive iodine therapy have less risk of developing Graves' eye disease.
Smokers are more prone to develop Graves' than nonsmokers so smoking cessation is routinely recommended.
In mild cases, cool compresses, sunglasses and artificial tears provide relief. People with Graves' eye disease often are advised to sleep with their heads elevated to reduce eyelid swelling. If double vision is a continuing problem, glasses containing prisms may be prescribed or surgery on the muscles may be advised. If the thyroid gland is overactive, anti-thyroid medications, radiation or surgery are standard options but radiation is not usually a first choice since it may make the eye disease worse.
A selenium supplement may help reduce swelling and decrease mild symptoms.
A corticosteroid drug, taken by mouth or intravenously, is the main therapy for Graves' eye disease. Oral prednisone is used most often when eye bulging and swelling continue to get worse. High dose prednisone or an intravenous corticosteroid is used if there is compression of the optic nerve. This is the most serious complication of Graves' eye disease.
Teprotumumab (Tepezza) is an alternative to corticosteroids. It is an FDA approved monoclonal antibody given by intravenous infusions. It inhibits the insulin-like growth factor 1 [IGF-1] receptor.
Another treatment option is immune suppressing medications (such as rituximab or mycophenolate).
In more stubborn cases, external radiation treatment of the eye socket may be considered to ease swelling. However, studies on the long term benefits of external radiation are not conclusive. Also radiation near the eye may damage the retina.
The most common surgery for Graves' eye disease is eyelid surgery to reposition the eyelid. In addition, surgery on the eye muscles can be done to realign the eyes. These procedures are performed by an eye specialist called an ophthalmologist.
When sight is threatened, a type of surgery called orbital decompression is done. In this procedure, a bone between the eye socket (orbit) and sinuses is removed to allow more space for the swollen tissues. This more complicated operation requires a medical center with expertise in this area.
It is important that thyroid blood levels be maintained in the normal range. After treatment of an overactive thyroid, there is a substantial risk of becoming hypothyroid (an under active gland). Thyroid replacement is essential to help keep Graves' eye disease from getting worse.
When To Call A Professional
Call your doctor if you notice any changes in the appearance of your eye or if you develop any of the symptoms of Graves' eye disease.
Most of the symptoms of Graves' disease, including eye symptoms, can be treated successfully.
American Thyroid Association, Inc.