Thyroid Eye Disease (TED)

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Risk factors

  • Smoking, female sex, radioactive iodine


  • Soft tissue involvement: Epibulbar hyperaemia, periorbital swelling, superior limbal keratoconjunctivitis
  • Eyelid retraction: widened palpebral fissure, superior and inferior “scleral show”
    • Dalrymple’s sign: superior scleral show in primary position
    • Graefe’s sign: “lid lag”, delayed/absent lowering of the upper eyelid when the gaze is lowered
    • Kocher’s sign: increased eyelid retraction during fixation, resulting in an anxious gaze
  • Exophthalmos: abnormal Hertel test if >20mm and/or difference of 2-3mm between both eyes
  • Exposure Keratopathy
  • Compressive optic neuropathy:
    • Visual acuity may be reduced
    • RAPD
    • Colour desaturation
    • Reduced contrast sensitivity
    • Visual field defects (central or paracentral)
    • Optic disc usually unremarkable, occasionally optic disc swelling, rarely optic atrophy
  • Restrictive myopathy: double vision, approx. 30 – 50% of patients develop ocular muscle palsy

Stages and therapy

1. Congestive (inflammatory) stage:

  • Red, painful eyes, remission within 3 years in most cases, in the long term approx. 10% with severe eye involvement.
  • Therapy depending on activity:
    • Lubricating eye drops, e.g. Lacrycon gtt, Vitamin A/Bepanthen Eye ointment
    • Consider local therapy with steroids, NSAID, Cyclosporine gtt
    • Stop smoking!
    • Selenase peroral solution 100mcg 2x daily
    • Methylprednisolone 500mg i.v. 1x weekly for 6 weeks, then 250mg i.v. 1x weekly for 6 weeks,
      • oral therapy obsolete
      • Steroid therapy should not be administered more frequently than once a year.
      • consider higher doses in severe cases
      • After steroid therapy, wait at least 3 months before radiotherapy is planned/performed, unless there is evidence of a compressive optic neuropathy.
    • Radiation therapy (a response is usually seen within 6 weeks)
    • Consider additional azathioprine or rituximab.
    • Consider teprotumumab (Cave: very expensive)
    • Surgical decompression

2. Fibrotic (quiet) stage

  • Quiet eyes without active inflammation, painless restrictive myopathy possible
  • Therapy: surgery in stable conditions without signs of activity for >6 months
    • In general, operations for TED are performed in the following order:
      • Orbita -> Strabismus -> Eyelids

Clinical Activity Scores (CAS)

Assessment of TED activity: 1 point each, for initial CAS only score items 1-7

  • Subjective activity symptoms
    • 1 Spontaneous orbital pain
    • 2 Gaze evoked orbital pain
  • Objective signs of inflammation
    • 3 Eyelid erythema
    • 4 Conjunctival redness
    • 5 Eyelid swelling
    • 6 Chemosis
    • 7 Caruncle and/or plica swelling
  • Signs of progression during follow-up examinations
    • 8 Increase of ≥ 2mm in proptosis in the last 1-3 months
    • 9 Decrease in ocular motility ≥ 8° in the last 1-3 months
    • 10 Decrease of visual acuity equivalent to 1 Snellen line in the last 1-3 months

Total score progression (max. 10 points)

  • Initial visit: Score ≥ 3 = active TED
  • Follow-up visit: Score ≥ 4 = active TED


  • Laboratory: TSH, fT3, fT4, TRAb, TPO-Ab, Tg-Ab
  • CT / MRI Orbit: typically thickened eye muscles without tendon involvement
  • OCT and Visual field examination in cases of suspected optic neuropathy

Therapy at a glance

  • Activity present: Severity?
    • mild: observation, smoking cessation, lubrification, optimise thyroid levels
    • moderate: steroids, radiotherapy
    • severe/malignant: steroids iv, rituximab, consider emergency decompression, teprotumumab
  • No activity present: stable?
    • Not stable: wait, re-evaluation after 6 months
    • stable: sequence of surgical treatment: decompression > strabismus surgery > eyelid surgery


  • EyeWiki Thyroid Ophthalmopathy
  • The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Nika Bagheri MD, Brynn Wajda MD, et al; Lippincott Williams&Wilkins; 7. Auflage (2016)
  • Kanski’s Clinical Ophthalmology: A Systematic Approach; Jack J. Kanski MD, Brad Bowling MD; Saunders Ltd.; 8. Auflage (2015)