Graves’ Thyroid Eye Disease: What Are The Treatment Options?

Graves’ disease is an autoimmune condition that results in hyperthyroidism. It’s more common in women¹ than men and usually begins from 30 to 50 years of age.¹ 

Hyperthyroidism occurs when the thyroid gland releases too much thyroid hormone. 

Graves’ disease can have a major impact on several organs in the body. It can also cause nervous system-related problems, such as palpitations, tremors, and anxiety, due to the body’s stress response.

In approximately 25% to 50% of Graves’ patients,² eye problems develop. 

If you have been diagnosed with Graves’ disease and notice eye symptoms, consult your doctor immediately. 

What is Graves’ disease of the eyes?

Graves’ disease of the eyes is called Graves’ ophthalmopathy or orbitopathy (GO) or Graves’ thyroid eye disease (TED). It refers to the symptoms of hyperthyroidism that manifest in the eyes. 

The underlying cause of Graves’ thyroid eye disease remains unclear. However, it is thought to be caused by an abnormal immune response targeting the healthy tissues around the eyes, causing swelling and congestion. 

If fat tissue (adipocytes) is involved, this can lead to increased fat expansion, increased eye pressures, and pinching of the optic nerves that supply the eye and allow you to see. 

If muscle tissue is involved (myofibroblasts), it can cause scarring of the eye muscles, causing difficulty for the eyes to move smoothly (restrictive myopathy). 

Symptoms of Graves’ orbitopathy

Below are the common symptoms of Graves’ ophthalmopathy:

• Itchy, watery, red, or dry eyes

• Puffiness around the eyes

• Eyelid lag and/or retraction

• Bulging eyes (proptosis)

• Double vision (diplopia) or loss of vision

• Swelling around the eyes (periorbital edema)

• Exposure keratitis (infections of the outer surface of the eye, from not being able to close the eyelids properly)

• Damage to the eye nerves (optic nerve neuropathy)

• Light sensitivity (photophobia) 

Treatment options for Graves’ ophthalmopathy

The right treatment for Graves’ ophthalmopathy depends on the extent of the disease and whether it is active or not. 

The active phase usually lasts between six months to two years. The inactive phase then follows, which is where disease progression has stopped.

Mild active disease

If your Graves’ orbitopathy is at the mild active disease phase, topical solutions such as artificial tears can be helpful. They maintain the tear film and reduce any redness and inflammation. 

This treatment is quick and easy, and you don’t need to worry about possible side effects as they are minor. Your eye specialist may also prescribe topical eye steroids that can help reduce inflammation.

Avoid wind, light, and pollutants like dust, smoke, and cosmetics to reduce eye dryness and irritation. Using cool compressors on the eyes also provides relief. 

Wear sunglasses when you go out to help with the light sensitivity. For double vision, prism glasses or patching one eye can help. 

At bedtime, keep your head elevated to help reduce congestion and aid drainage.

Moderate and severe active disease

If you have a moderate and severe active disease, steroids administered either orally or administered into the veins can be helpful. Steroids help reduce the inflammation process and decrease the congestion of the orbital tissues. 

The benefit of intravenous steroids is that they work very quickly to reduce inflammation and provide prompt relief. 

If systemic steroids are considered too risky due to conditions such as diabetes, steroids can be injected directly into the orbit of the affected eye. 

Orbital radiation can also be used in conjunction with steroids to reduce inflammation. Rare side effects include early cataract formation and damage to the retina. 

Teprotumumab (Tepezza) is the first FDA-approved drug to treat thyroid eye disease. It is the only medicine to date that has been shown to halt the progression of active GO and improve symptoms such as double vision and eye bulging. It is given via an intravenous infusion. 

Emergency orbital decompression by removing bone or soft tissue helps create more space. This gives immediate relief but is a very invasive type of surgery. 

Inactive disease

When your GO is stable (an inactive disease), you can look at more permanent options to reduce the pressure inside your orbit and hopefully improve the symptoms in your eyes. 

These treatments include:

Orbital decompression 

Orbital decompression is done by removing fat tissues. This procedure is invasive and can be painful, and you are also at risk of developing postoperative double vision.

Bony decompression (of the two outer walls)

This increases the orbital space and results in a reduction of bulging eyes. Some risks of this procedure include pain, double vision, sinus bleeding, and cerebrospinal fluid (CSF) leakage. 

Corrective surgery

Strabismus corrective surgery can restore eye alignment, which should resolve double vision. 

Eyelid repair

While eyelid repair has cosmetic value, it also improves eyelid function. It helps protect the eyes and reduces exposure that could cause conditions like corneal ulcers.

Treating the root cause of Graves’ orbitopathy

All the above treatments are specifically for GO as a complication of Graves’ disease and hyperthyroidism. 

For permanent treatment of the root cause of Graves’ orbitopathy, normal thyroid hormone levels to improve organ functions (e.g., eyesight, sexual function, stress responses, metabolism) is important. 

Three main modes of therapy for Graves’ disease and hyperthyroidism are available:

1. Antithyroid drugs

2. Radioactive iodine (RAI) therapy

3. Partial or complete surgical removal of the thyroid gland

Generally, only the latter two provide any certainty of remission, although antithyroid medication is often given as a first-line treatment. 

If a stable thyroid hormone state isn’t reached within 12 to 18 months, surgery or RAI become preferable options to remove the thyroid. 

It’s worth bearing in mind that radioactive iodine treatment often worsens symptoms in the eyes.

Research has established that GO symptoms are worse if you are a smoker.³ Quitting smoking is one of the best things you can do to prevent GO, reduce the severity of its symptoms, and improve your body’s response to the treatments mentioned above. 

The lowdown

Graves’ orbitopathy is a complication of Graves’ disease and hyperthyroidism in up to 50% of patients. It can be mild or severe, but in either case, it can be debilitating and can diminish your quality of life. 

Because Graves’ ophthalmopathy can have a lasting impact on your vision, it’s imperative to consult your doctor so that they can treat your symptoms immediately