Thyroid eye disease (TED) is an autoimmune condition affecting the muscles and fat behind the eyes, most commonly linked to Graves' disease. It has an active inflammatory phase and an inactive stable phase. Treatments range from selenium supplements for mild disease to Tepezza infusions for moderate-to-severe active TED.
Thyroid eye disease (TED) — also called Graves' orbitopathy or thyroid-associated ophthalmopathy — is an autoimmune condition in which the immune system attacks tissues in and around the eye socket. While closely linked to Graves' disease, it can occur even when thyroid function is normal and requires its own separate evaluation and treatment.
The Connection to Graves' Disease
In Graves' disease, the immune system produces antibodies (TRAb — thyrotropin receptor antibodies) that stimulate both the thyroid and eye socket tissues. About 25–50% of people with Graves' disease develop noticeable TED. Treating the thyroid (radioactive iodine, medications, surgery) does not automatically treat TED and in some cases may temporarily worsen it — particularly radioactive iodine, which can trigger or exacerbate TED.
🚭 Stop Smoking: Smoking is the most important risk factor for developing and worsening TED. Smokers have 7–8x higher risk and respond less well to all treatments. If you have Graves' disease, quitting smoking is the single most important thing you can do to protect your eyes.
Symptoms
- Proptosis (eye bulging / exophthalmos): The most recognizable sign — eyes appear to protrude forward
- Diplopia (double vision): From inflammation and enlargement of eye muscles
- Periorbital edema: Puffy eyelids, especially in the morning
- Eye pain or pressure
- Light sensitivity (photophobia) and excessive tearing
- Lid retraction: Upper eyelid pulled back, giving a "staring" appearance
- Exposure keratopathy: Corneal damage from inability to close the eye fully
- Dysthyroid optic neuropathy (DON): Vision loss from optic nerve compression — rare but serious emergency
Active vs. Inactive TED
TED follows a predictable course:
- Active (inflammatory) phase: Lasts 6 months to 2 years. Symptoms worsen progressively. This is the window when anti-inflammatory treatments are most effective.
- Inactive (stable) phase: Inflammation resolves but structural changes (proptosis, double vision) may persist. Surgery is considered only in the inactive phase.
The Clinical Activity Score (CAS) — based on pain, redness, swelling, and other signs — is used to assess whether TED is active. CAS ≥3/7 indicates active disease.
Treatment Options
| Severity | Treatment |
|---|---|
| Mild active | Selenium 200 mcg/day × 6 months (evidence-based); lubricating eye drops; UV-protective sunglasses; sleep with head elevated; quit smoking |
| Moderate-severe active | Tepezza (teprotumumab) IV infusions — 8 infusions over 24 weeks; OR IV methylprednisolone (high-dose steroids) |
| Optic nerve compression (DON) | Emergency IV steroids → urgent orbital decompression surgery if no improvement |
| Inactive phase (residual) | Orbital decompression, strabismus surgery (for diplopia), or lid surgery — in that sequence, after inflammation resolves |
Tepezza (Teprotumumab)
Tepezza is the first FDA-approved medication specifically for TED. It is an IGF-1 receptor inhibitor given as 8 IV infusions every 3 weeks. Clinical trials showed an average 3mm reduction in proptosis and resolution of double vision in ~65% of patients. Side effects include nausea, muscle cramps, hair loss, and hearing changes. Insurance prior authorization is required; our office can assist.
Key Takeaways
- TED is an autoimmune eye condition closely linked to Graves' disease but can occur with normal thyroid function
- Smoking increases TED risk 7–8x — quitting is the single most important intervention
- Active phase (6 months – 2 years) is when treatment is most effective; inactive phase is for surgical correction
- Tepezza (teprotumumab) is the first FDA-approved treatment for TED — 8 IV infusions over 24 weeks
- Mild TED can be treated with selenium 200 mcg/day for 6 months (evidence-based)
- Vision loss from optic nerve compression is a medical emergency requiring immediate treatment
- Radioactive iodine can worsen TED — discuss risks with your endocrinologist
Our Team Can Help
All five of our providers diagnose and manage endocrine conditions. Book with any member of our team:
Book an Appointment → or call 832-968-7003