Lid/Orbit
Thyroid Eye Disease
Also known as: TED, thyroid eye disease, Graves' ophthalmopathy, Graves' orbitopathy, thyroid orbitopathy, dysthyroid ophthalmopathy, infiltrative ophthalmopathy, thyroid proptosis
Filed as: Urgent
Source-cited from the record's own evidence list. Clinical content programme led by Dr Ankit Mathur, PhD, Grad Cert Ocu Thera, B.S. Optom. How the clinical content is governed
Clinical decision support only
Overview
An autoimmune orbital inflammatory disease associated with thyroid dysfunction — most commonly Graves' hyperthyroidism, but can occur with hypothyroidism or euthyroid state. Caused by autoantibodies against the TSH receptor in orbital fat and extraocular muscles. Presents with proptosis, lid retraction, restrictive myopathy (diplopia), and conjunctival injection. Dysthyroid optic neuropathy (DON) is the sight-threatening complication.
Recognition
Symptoms: what patients report
- Proptosis — forward protrusion of one or both eyes.
- Lid retraction — the upper lid sits above the superior limbus (scleral show above the cornea).
- Diplopia — double vision from restrictive extraocular myopathy (inferior and medial recti most commonly affected).
- Periorbital aching or orbital discomfort.
- Gritty, red, watery eyes from exposure keratopathy.
- Reduced vision and colour vision in dysthyroid optic neuropathy (DON).
- Periorbital puffiness and lid oedema in the active phase.
- History of thyroid disease or thyroid treatment.
Signs: what the examination shows
- Proptosis — Hertel exophthalmometry > 20mm or asymmetry > 2mm.
- Lid retraction: upper lid above the superior limbus; lower lid at or below the inferior limbus.
- Lagophthalmos: inability to fully close the eyelids — risk of exposure keratopathy.
- Lid lag on downgaze: upper lid lags behind the globe as the patient looks down.
- Restricted eye movements: limited upgaze (inferior rectus fibrosis), limited abduction (medial rectus fibrosis).
- Conjunctival injection and chemosis over the extraocular muscle insertion sites.
- Corneal exposure changes: inferior punctate staining, SPK.
- RAPD or colour vision loss: indicates dysthyroid optic neuropathy — emergency.
- Clinical Activity Score (CAS) ≥3/7 indicates active disease: lid oedema, lid erythema, conjunctival injection, chemosis, caruncle oedema, spontaneous pain, pain on eye movement.
What OptoGuide™ covers for thyroid eye disease
- Pattern reasoning: what this combination of findings points to, and its differentiators
- Don't-miss risks and escalation triggers
- Management tiers with linked Australian therapeutics
- Referral urgency, specialty, and letter drafting
Sources
- Thyroid Eye Disease — EyeWiki
- Thyroid associated orbitopathy — Referral Access Criteria (WA Health)
- Management of Thyroid Eye Disease: A Consensus Statement by the American Thyroid Association and the European Thyroid Association. Burch HB, Perros P, Bednarczuk T, et al. Thyroid : Official Journal of the American Thyro
- Orbital Diseases Mimicking Graves' Orbitopathy: A Long-Standing Challenge in Differential Diagnosis. Marinò M, Ionni I, Lanzolla G, et al. Journal of Endocrinological Investigation. 2020;43(4):401-411.
- Thyroid Eye Disease (Graves' Orbitopathy): Clinical Presentation, Epidemiology, Pathogenesis, and Management. Wiersinga WM, Eckstein AK, Žarković M. The Lancet. Diabetes & Endocrinology. 2025;13(7):600-614.
Standard texts: Kanski's Clinical Ophthalmology: A Systematic Approach, The Wills Eye Manual, Oxford Handbook of Ophthalmology, Oxford American Handbook of Ophthalmology, Signs in Ophthalmology: Causes & Differential Diagnosis.