Thyroid Eye Disease: The 7 Signs You Should Never Ignore

Experiencing issues with your thyroid gland is more common than you might think. Whether you have hyperthyroidism, hypothyroidism, or even normal thyroid function, you’re still at risk of developing what's known as Thyroid Eye Disease (TED). Unfortunately, many medical professionals, including eye care specialists, often overlook the early signs of this condition, leading to it being underdiagnosed.

In this article, we’ll explore the seven key signs of Thyroid Eye Disease that you should be aware of, so you can take proactive steps if you notice any of them.

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Today, we’re diving into the often overlooked connection between thyroid problems and eye health. Let’s break down the seven signs of Thyroid Eye Disease.

1. Eyelid Retraction

The first sign of TED is eyelid retraction, a condition that occurs in about 80% of people diagnosed with the disease. Eyelid retraction gives the eyes an “alarmed” or “staring” appearance, which is often referred to as "scleral show." Normally, the upper eyelid should rest just below the top part of the cornea, so you shouldn’t see the white part (sclera) above the cornea unless someone is surprised. However, if you can see this white area during a normal conversation, it could be an early indicator of TED.

In my practice, I often teach my students to perform a simple test for lid lag, where the patient is asked to follow a finger or a pen as they look up and down. Lid lag occurs when one eyelid appears higher than the other during this movement, and it’s usually more pronounced in one eye due to the asymmetrical nature of TED. This test helps us detect early signs of eyelid retraction, which is crucial for early diagnosis.

Additionally, we look for something called the Van Graefe sign, which is the dynamic aspect of lid lag. Here, we observe if one eyelid falls slower than the other when the eyes move downward. While it’s a more challenging sign to detect, it’s an important clue in diagnosing TED.

2. Proptosis (Exophthalmos)

Proptosis, also known as exophthalmos, is perhaps the most well-known sign of Thyroid Eye Disease. This is where the eyeballs appear to bulge outward, giving the eyes a protruding look. This occurs because the muscles surrounding the eye become inflamed and swollen due to the thyroid problem. The inflammation causes these muscles to push against the eyeball, leading to the characteristic bulging.

This symptom is particularly common in people with Graves’ disease, an autoimmune condition associated with hyperthyroidism. While proptosis is the symptom most commonly associated with TED, it only affects about 60% of those with the condition. Nevertheless, it’s one of the most striking and easily recognizable signs. If you notice someone with bulging eyes, it's essential to consider a thyroid issue, and you can almost diagnose TED from a distance.

3. Diplopia (Double Vision)

The third sign of Thyroid Eye Disease is diplopia, commonly known as double vision. This occurs due to restrictive orbital myopathy, where the eye muscles become swollen and fibrotic, limiting their movement. Diplopia is particularly prevalent when the inferior rectus muscles (responsible for moving the eyes downward) are affected first, followed by the medial recti (which move the eyes inward), and then the superior and lateral recti.

People with TED often experience vertical diplopia, where they see double images stacked on top of each other. To compensate, they may tilt their heads to one side to align their vision. When the medial recti muscles are involved, it can cause an esotropia, where one eye turns inward, leading to double vision in a side-to-side pattern. This type of diplopia is a telltale sign of TED and should prompt immediate evaluation by an eye care professional.

4. Pain with Eye Movement

Pain with eye movement is another common but often misunderstood symptom of Thyroid Eye Disease. Patients may describe this pain as a dull, aching sensation, rather than a sharp pain. This discomfort occurs because the swollen eye muscles are being strained during eye movement.

While most people can feel a slight tension when moving their eyes to extreme positions, TED-related pain is more pronounced and can occur with even small eye movements. This pain is a significant indicator that the eye muscles are inflamed and struggling to function properly.

It’s also important to differentiate this type of pain from other conditions, such as optic neuritis, where pain occurs due to swelling of the optic nerve. In TED, the pain is specifically due to muscle restriction, making it a key symptom that should not be ignored.

5. Dry Eyes

Dry eyes are a perplexing symptom of Thyroid Eye Disease, often catching both patients and doctors off guard. The connection between dry eyes and thyroid conditions lies in the fact that proptosis causes the eyelids to not close completely. This incomplete closure, known as lagophthalmos, leads to the eyes being exposed to the air for extended periods, causing the tears to evaporate too quickly.

This exposure leads to a condition called exposure keratopathy, where the surface of the eye becomes irritated and damaged due to the lack of moisture. Additionally, some patients may develop Superior Limbic Keratoconjunctivitis (SLK), a condition where the upper part of the eye becomes red and inflamed due to constant friction with the eyelid.

As an eye care professional, I often flip the upper eyelid during examinations to check for redness or irritation that could indicate SLK. If found, it’s a strong indication that the patient may have an underlying thyroid condition that needs further investigation.

6. Eyelid and Eye Surface Swelling (Edema and Chemosis)

The sixth sign of Thyroid Eye Disease is swelling of the eyelids and the eye surface, medically known as edema and chemosis. Patients may notice a gelatinous swelling on the surface of the eye, along with redness, particularly at the 3 o’clock and 9 o’clock positions of the eye.

This swelling occurs because the eyes are pushed forward due to the inflammation of the eye muscles, causing the eyelids to not close completely. This incomplete closure allows inflammatory proteins to accumulate on the eye's surface, leading to the swelling and redness that are characteristic of TED.

Recognizing this symptom early is crucial because it indicates that the inflammation is significant and could lead to more severe complications if left untreated.

7. Optic Neuropathy

The final and most serious sign of Thyroid Eye Disease is optic neuropathy. This condition, which occurs in about 6% of TED cases, involves the compression of the optic nerve by the swollen eye muscles. When the optic nerve is compressed, it can lead to permanent vision loss if not treated promptly.

Optic neuropathy is particularly concerning because it often progresses slowly, meaning patients may not notice the loss of vision until it’s too late. Regular eye examinations and monitoring of thyroid levels are essential for catching this condition early and preventing irreversible damage.

Conclusion

Thyroid Eye Disease is a complex condition that can have serious implications for your vision and overall eye health. Fortunately, by being aware of these seven signs, you can take action early and seek the necessary medical attention.

If you suspect that you or someone you know may have Thyroid Eye Disease, it’s important to consult with both your eye care professional and your primary care doctor. They can work together to conduct the appropriate tests, including thyroid panels and eye measurements, to ensure that you receive the right diagnosis and treatment.

The good news is that there are effective treatments available for TED, ranging from medications to surgical interventions like orbital decompression surgery. The sooner the condition is detected, the better the outcomes tend to be.

Remember, your health is in your hands, and being informed is the first step toward taking control. If you found this information helpful, don’t forget to hit that like button and leave a comment below with any questions you may have. Your questions might inspire future videos, so don’t hesitate to reach out!

Thanks for reading, and until next time, keep an eye on your health!