Thyroid Eye Disease: Symptoms and Treatment
Bulging eyes, eyelid retraction, dryness and double vision: how does thyroid disease affect the eyes, which symptoms are urgent, and how do we treat it?
Thyroid disease can affect the eyes. Thyroid eye disease is most common in Graves disease, where the thyroid is overactive. The tissue and muscles behind the eye swell. As a result, the eyes bulge and the upper eyelid retracts. The eyes also become dry and red, and double vision can occur. In Hashimoto disease, where the thyroid is underactive, dryness and swelling around the eyes can also occur. Treatment rests on three steps: keeping thyroid levels in balance, quitting smoking and protecting the eye surface. Active, moderate-to-severe disease needs medication, and permanent changes need surgery.
How does thyroid disease affect the eyes?
In Graves disease, the thyroid gland is overactive. The immune system then attacks more than the thyroid. It can also target the fat tissue and the eye muscles in the eye socket. When these tissues become inflamed and swollen, they push the eye forward. The eyelids also retract. Doctors call this condition thyroid eye disease (Graves orbitopathy).
In Hashimoto disease, the thyroid is underactive. Here we mostly see dry eyes and swelling around the eyes. However, thyroid eye disease can also develop in Hashimoto disease, although less often. Eye findings can also appear when thyroid levels are normal.
“Thyroid disease can push the eye forward, widen the eyelid opening and dry out the eye surface. In advanced cases, it can also affect the optic nerve. Endocrinology and eye follow-up should go hand in hand.”
— Prof. Dr. Fırat Helvacıoğlu, from the video
Thyroid disease can affect your eyes
Prof. Dr. Fırat Helvacıoğlu explains how thyroid disease affects the eyes.
What changes in the eye in thyroid eye disease?
The immune reaction linked to the thyroid swells the fat tissue and muscles around the eye. As a result, the eyelid retracts, the eye bulges and the eye surface dries out.
- Normal appearanceThe upper eyelid slightly covers the top edge of the iris. The eyelid protects the eye surface well.
- Eyelid retractionThe upper eyelid pulls upward, so white shows above the iris. The gaze looks “startled”, and the eye dries out and turns red.
- Bulging eyeAs the tissue behind the eye swells, it pushes the eye forward past the bony rim. The eyelids may then fail to close fully.
Symptoms of thyroid eye disease
- Stinging, burning, a gritty feeling and watering of the eyes
- Redness and swollen eyelids, especially in the morning
- Bulging eyes, with white showing above or below the iris
- Pain when moving the eyes, and double vision
- Sensitivity to light and difficulty closing the eyes fully
Symptoms can affect one eye or both, and to different degrees. Usually, the disease first goes through an active inflammatory phase that lasts from a few months to two years. After that, it settles into a quiet (inactive) phase.
When is it an emergency?
Seek care the same day
- Reduced vision, or colors that look faded
- Double vision that starts suddenly or quickly gets worse
- Pain and blurred vision in the cornea because the eye cannot close
These symptoms can be a sign of pressure on the optic nerve or damage to the cornea. They need urgent treatment.
Treatment
| Situation | Approach |
|---|---|
| All patients | Balancing thyroid levels, quitting smoking, artificial tears and protecting the eye surface |
| Mild and active disease | Surface treatment and monitoring; selenium supplements in some patients |
| Moderate-to-severe and active disease | Intravenous cortisone treatment and, when needed, other immune-modulating drugs |
| Sight-threatening disease | High-dose cortisone; if there is no response, urgent orbital decompression surgery to make more room in the eye socket |
| Changes that remain in the quiet phase | Decompression, strabismus and eyelid surgery (in this order) |
The 2021 guideline of the European Group on Graves’ Orbitopathy (EUGOGO) recommends planning treatment by the severity and activity of the disease. It also recommends surgery usually after the disease has become quiet. For this reason, we always check for thyroid eye disease before eyelid surgery.
Smoking and thyroid eye disease
Smoking is the most important modifiable factor that raises the risk of developing thyroid eye disease and of it getting worse. It also reduces the response to treatment. If you have thyroid disease, quitting smoking is one of the most effective steps you can take to protect your eyes. If radioactive iodine treatment is planned, we recommend an eye assessment first. We also recommend protective treatment when needed.
Frequently asked questions
The active inflammatory phase usually settles within a few months to two years. Some changes can fade on their own. Surgery can correct any that remain during the quiet phase.
The eyeball does not grow. However, the tissue and muscles behind the eye swell, so the eye is pushed forward and the eyelids retract. That is why the eyes look larger.
In Hashimoto disease, we mostly see dry eyes and swelling around the eyes. Less often, thyroid eye disease can also develop.
Usually, the disease has been in the quiet phase for at least a few months. If needed, the surgeon first performs decompression and strabismus surgery.
If you have no eye symptoms, one eye exam at diagnosis and during treatment may be enough. If you have symptoms, we set the follow-up interval according to the activity of the disease.
Related pages
References
- Bartalena L, Kahaly GJ, Baldeschi L, et al. The 2021 European Group on Graves’ orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves’ orbitopathy. Eur J Endocrinol. 2021;185(4):G43-G67. doi:10.1530/EJE-21-0479
- Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017;15(3):276-283. doi:10.1016/j.jtos.2017.05.008
This article is for patient information. It does not replace an examination or medical assessment. We decide on the right treatment after an eye exam and measurements. Publication date: 25 September 2026.
Contact Prof. Dr. Fırat Helvacıoğlu with your questions
Prof. Dr. Fırat Helvacıoğlu · Veni Vidi Eye Clinic, Bağdat Cad. No: 257, Caddebostan – Kadıköy / Istanbul