Thyroid eye disease (TED) is typically seen in individuals with Graves disease, but also is found in Hashimoto thyroiditis. Similar to conjunctival icterus, it is a sign of underlying disease that must be explored. TED has many eye signs but is typically characterized by eyelid retractions, lid lag, redness (erythema), conjunctivitis, and bulging or “bug” eyes (exophthalmos). This is due to the autoimmune process of the disease, where autoantibodies target eye muscle fibroblasts, which change into fat, expand, and become inflamed, leading to manifestations of TED.
Thyroid Eye Disease. Lateral lid retraction (temporal flare) with scleral show is seen in this patient with chronic hyperthyroidism. (Used with permission from The University of Iowa and EyeRounds.org.)
Thyroid Eye Disease. Marked chemosis is seen in this patient with hyperthyroidism. (Photo contributor: Lawrence B. Stack, MD.)
Management and Disposition
TED is diagnosed clinically when presenting to the ED. Thyroid hormones (triiodothyronine, free thyroxine, thyroid-stimulating hormone) and imaging (CT or magnetic resonance imaging [MRI] orbits) can support the diagnosis. Once diagnosed, regulating hormone levels is key and referral to an endocrinologist is key for long-term management of the underlying disease. However, TED will progress independently of the thyroid disease and should be managed separately. Systemic steroids in conjunction with orbital radiation and immunotherapy (eg, rituximab, teprotumumab) can be used initially before considering surgical interventions.
TED is a sign of underlying thyroid disease that is looming.
Early recognition of TED is crucial for determining the appropriate management for preservation of vision.