Thyroid Eye Disease

If you have blurry vision and eyes that are red, dry, or watery, you might suspect anything from allergies to dry eyes. Many eye-care providers might treat your eye problem with antihistamines, artificial tears, or a round of antibiotics. But if your real ailment is a condition called thyroid eye disease (TED)—which has additional signs and symptoms that set it apart from other conditions—such remedies will not get to the root of your problems and, in fact, may exacerbate your symptoms.

Knowing more about this uncommon but potentially devastating eye condition could mean getting the help you need faster. And that could make a lifelong difference in your vision, appearance, and quality of life.

What is TED?

TED is an autoimmune disease, meaning it’s caused by your own immune system attacking tissues in your eyes. About 90 percent of people with TED have harmfully high levels of thyroid hormones, a condition known as hyperthyroidism or Graves’ disease, which is caused by an immune attack on the thyroid gland. The immune proteins that target the thyroid gland can also target muscles and fatty tissues surrounding the eyes. TED can develop before or after thyroid hormone levels rise, and rarely some people with TED may have normal thyroid levels. It’s even possible to have TED with low thyroid levels.

Thyroid eye disease progresses during an active, initial stage that typically lasts for six months to two years. Some people recover fully after this stage, but others have lingering effects.

Symptoms of TED

The hallmark of TED is a distinctive change in appearance. The eyes bulge or seem to constantly stare and can get inflamed, and swelling in the back of the eye can push the eyeballs forward. At first, the changes may be subtle, but a doctor who knows what to look for will see a telltale sign: the upper lid will sit higher than the colored part of the eye—like a window shade opened a little too widely. Affected individuals may have a staring, wide-eyed look.

Many people become anxious or depressed about the change in their appearance. They say they  don’t look or feel like themselves. But TED isn’t just a cosmetic issue. Other signs and symptoms can include:

• Dryness or a feeling of grittiness in the eyes. This results, in part, from the front of the eye being more exposed to air and dust as the eye pushes forward and the eyelids retract.
• Redness in the eyes and red, swollen eyelids.
• Bags around the eyes, caused by swollen tissues.
• Pain in or around the eyes, especially when looking up, down, or sideways.
• A low tolerance for bright lights.
• Difficulty or pain with moving the eyes, which can result in blurred or double vision. These vision changes can make it hard to drive, read, and do other everyday tasks.
• Visual loss. This can happen if the corneas, the clear front windows of the eyes, are severely damaged by extreme dryness or if swelling tissues compress and damage the optic nerve, the cable at the back of each eye that sends visual signals to the brain. These complications happen in a small number of patients.

Diagnosis

If a doctor suspects you have TED, the first step will be to take blood samples to test for thyroid levels and levels of certain antibodies involved in the disease. You might also get some imaging tests, such as an ultrasound, a CT scan or MRI, so your doctor can look for any changes in the tissues around your eyes.

Treatment

Since most people with TED have high thyroid levels, which can cause symptoms such as anxiety, tremors, weight loss, and excess sweating, it’s a good idea to see an endocrinologist, a doctor who specializes in hormone disorders. The specialist or a primary care doctor will prescribe treatments to normalize thyroid levels. These can include medications and surgery. Keeping thyroid levels stable and normal is very important and can greatly help the eye symptoms.

One treatment for high thyroid levels, radioactive iodine, has been shown to worsen eye disease in some patients. But doctors can adjust the ways they administer the drug to minimize those effects.

An ophthalmologist, a medical doctor specializing in eye health, can offer additional treatments to address the eye problems associated with TED. Early treatment, during the active stage of the disease, can often reverse or limit progression.

If you have mild symptoms, you may get relief with a few simple remedies and lifestyle changes:

• Artificial tears are available without a prescription. These can help lubricate the eyes and ease dryness. Some people with more severe dryness may need lubricating ointments or gels.
• Quitting smoking. Smoking worsens inflammation, and people who quit after their diagnosis are less likely to progress to more severe symptoms.
• Dietary changes. A diet that lowers inflammation throughout the body can make a difference. That means limiting sugar, highly processed foods, and alcohol and loading up on leafy greens, other vegetables, fruits, and whole foods. Foods rich in omega-3 fatty acids, such as fish, and/or nutritional supplements may also help. It’s also important to get enough vitamin D.
• Selenium supplements. Studies show that taking 200 micrograms of the mineral selenium each day can help reduce TED symptoms. You can get selenium in most multivitamins. (But don’t rely on vitamins to make up for a poor diet).
• Prism eyeglasses. These glasses with special lenses can help correct double vision. Sunglasses also can help with light sensitivity.

People with more severe symptoms may need to see an ophthalmology team that specializes in TED and can offer more aggressive treatments:

• Infusions with a recently approved medication called teprotumumab-trbw (Tepezza). This drug can reduce eye bulging and double vision and may allow many patients who would otherwise need surgery to avoid it. It is given intravenously as eight infusions, spaced three weeks apart. Side effects can include nausea, diarrhea, and muscle spasms. Some people with diabetes see increases in blood sugar, and some patients report hearing loss.
• Steroid pills or injections. Drugs such as prednisone can be used temporarily to reduce inflammation and swelling. These drugs can cause mood swings, fluid retention, and other side effects.
• Radiation. In some cases, orbital radiation may be used to reduce eye swelling. This therapy is used less commonly today.
• Surgery. If the optic nerve is at risk, a procedure to relieve pressure on the nerve, called decompression surgery, may be done while the disease is still in the active stage. In the rehabilitative phase of the disease, decompression surgery can be done to relieve the bulging of the eyes. Eye muscle surgery is performed for double vision and eyelid surgery to improve appearance and function.