Graves’ Ophthalmopathy

Sometimes our eyes can get gritty and uncomfortable. While it’s common to get something stuck in your eye, experiencing it frequently with other symptoms can be concerning. 

One such concern is Graves’ Ophthalmopathy. Fortunately, it is manageable, and early intervention can safeguard both your vision and your confidence. 

Here’s what you need to know and the actions you can take right away.

What is Graves’ Ophthalmopathy?

Graves’ Ophthalmopathy is an autoimmune disease that occurs when the immune system attacks the tissues around the eyes. It’s also referred to as:

• Graves’ eye disease
• Thyroid eye disease
• Graves’ orbitopathy
• Thyroid-associated ophthalmopathy

Around one in three people with Graves' disease develop Graves’ ophthalmopathy. Graves' disease causes the thyroid gland to produce too much thyroid hormone (hyperthyroidism), affecting the rate of metabolism in the body.

Although it’s rare, severe forms of Graves’ eye disease can lead to vision loss. See your doctor right away if you experience symptoms of Graves’ eye disease.

What Causes Graves’ Ophthalmopathy?

Graves’ ophthalmopathy results from an autoimmune reaction in which the immune system attacks tissues around the eyes. 

Graves’ disease causes the immune system to attack the muscles around your eyes (extraocular muscles). 

This leads to swelling behind your eye sockets, resulting in symptoms like bulging or difficulties closing the eyelids. Because thyroid hormones play a vital role in various body systems, the disease severity of Graves’ ophthalmopathy can differ significantly.

How Does the Condition Affect Your Eyes?

Graves’ disease doesn’t stop at affecting your thyroid; it often involves your eyes, too. When you have Graves’, your immune system mistakenly attacks your own tissues, including those in the eye sockets (orbits). 

Antibodies that normally target the thyroid gland interact with tissues around your eyes, causing inflammation and swelling. About 25 to 50 % of people with Graves’ disease experience noticeable eye symptoms.

These symptoms often progress through two phases: an active phase that lasts for 6 to 18 months and a stable (inactive) phase where the inflammation subsides, leaving potential lasting changes like eyelid retraction or bulging eyes.

What Are the Symptoms of Graves' Ophthalmopathy?

Eye symptoms associated with Graves’ disease are generally mild and easy to treat. Graves’ eye disease typically affects both eyes, but symptoms may only be apparent in one eye.

Common symptoms of Graves’ eye disease include:

• Dry, itchy, irritated eyes
• Bug-eyed look due to bulging eyes
• Light sensitivity (photophobia)
• Teary eyes
• Eyelid swelling and redness
• Eye pain or pressure around the eyes
• Trouble closing the eyes completely
• Double vision (diplopia)
• Pain when you move your eyes either up and down or left to right

Who is At Risk of Developing Graves' Ophthalmopathy?

Graves’ disease is the underlying health problem in nearly all cases of Graves’ ophthalmopathy. Women and people over age 40 are more likely to develop Graves’ disease.

Other risk factors for Graves’ eye disease include:

• Smoking cigarettes
• Uncontrolled hyperthyroidism
• Receiving radioactive iodine treatment
• Having a family history of Graves’ disease
• Having another autoimmune disease, such as rheumatoid arthritis or Crohn’s disease

Not only does smoking increase your risk for Graves’ eye disease, but it also makes the condition more severe. This is because smoking compromises the immune system, increasing your risk for various diseases.

How Is Graves’ Eye Disease Diagnosed? 

To diagnose Graves’ eye disease, your eye doctor will conduct a comprehensive eye exam to examine your eyes and eyelids carefully. They will also review your medical and family history and perform a physical exam.

Your doctor may recommend additional testing to diagnose Graves’ disease as an underlying cause of other symptoms. They may also conduct one or more of the following tests to diagnose the condition:

• Blood tests
• Radioactive iodine uptake test
• Thyroid scan
• Doppler blood flow measurement

How Is Graves’ Eye Disease Treated?

Treatments for Graves’ eye disease vary depending on the severity of your symptoms. Mild thyroid eye disease is typically not highly progressive and often goes away on its own, usually lasting approximately 1-2 years.

If your eye symptoms are severe, or if home remedies don’t work, your doctor may recommend one or more of the following:

• Prescription medicines. Oral steroids like prednisone can reduce swelling. Your doctor may also prescribe teprotumumab, which specifically treats Graves’ eye disease.
• Thyroid hormone medication. Taking medication to balance your thyroid hormones can help relieve symptoms. This typically involves antithyroid drugs (such as methimazole) or other treatments that lower high hormone levels.
• Special eyeglasses. To fix double vision and help you see more clearly.
• Orbital radiotherapy. A radiation treatment to help reduce swelling around the eyes.
• Orbital decompression surgery. This procedure makes the eye socket larger, which helps relieve pressure on the optic nerve and can help move the eye into a more comfortable position.

Home Remedies for Graves’ Disease

Most cases of Graves’ eye disease are mild and can be managed at home. Home remedies include:

• Over-the-counter eye drops (artificial tears) can relieve irritation and dry eyes.
• Wearing sunglasses can help manage light sensitivity and prevent you from exacerbating symptoms.
• Sleeping with your head slightly elevated can help reduce eyelid puffiness and swelling.
• Taping your eyelids shut at night helps prevent dry eyes.
• Under medical supervision, selenium supplements can benefit people with mild, active thyroid eye disease, but evidence is mixed and benefits are not universal.
• Quit smoking.

Is Surgery Necessary for Graves’ Ophthalmopathy?

Surgery for TED is typically performed after the active inflammation settles (6 to 12 months). Procedures are done sequentially to address specific issues:

• Orbital decompression. Removes orbital bone and fat, reducing eye bulging significantly.
• Strabismus (eye muscle) surgery. Corrects double vision caused by muscle stiffness.
• Eyelid surgery (oculoplastics). Adjusts eyelid position to improve appearance and comfort.

Real-world outcomes generally show high patient satisfaction, often significantly improving appearance, function, and confidence.

When Should You Call A Doctor?

Most TED cases aren’t emergencies, but some symptoms need urgent attention. Immediately contact your eye specialist if you experience:

• Sudden dimming or loss of vision: Indicates potential optic nerve compression and requires immediate treatment.
• Corneal ulcer signs: Severe pain, blurred vision, and excessive tearing may indicate potential damage to the eye’s surface.
• Rapid onset of severe double vision or eye pain: Suggests worsening inflammation or muscle swelling needing quick intervention.