Graves disease

Thyroid eye disease is inflammation around the eye and is associated with Graves thyroid disease. The typical early warning symptoms of red eyes, recurrent or persistent eyelid swelling or puffiness around the eyes, or chronic watery eye (epiphora) should not be ignored. Whilst changes are often slow, they can occur suddenly. When severe, the disease causes disfigurement, double vision and blindness. 


Thyroid eye disease is an autoimmune disease, more common in females than males and its exact trigger remains unknown. Thyroid eye disease can be associated with diabetes or myasthenia gravis and is worse in cigarette smokers.


The typical patient is female in her 40’s complaining of puffy eyelids, which they often interpret as a cosmetic problem rather than disease. They usually discuss their symptoms with friends but are less inclined to mention these to their GP, feeling that such concerns would be interpreted as ‘vanity’. Suspicion is higher if the patient develops asymmetry.

Clinical features

The early features of Thyroid eye disease are:

  • puffiness of the upper and/or lower eyelids
  • redness or swelling of the conjunctiva (chemosis)
  • watery eyes, typically associated with puffiness
  • wide eyed stare
  • unequal eyelids

As the disease progresses, more established features occur like exophthalmos (bulge of the eyeball), double vision, and asymmetry of upper and lower eyelid. Loss of vision may occur at any time, but more typically with advanced disease.


Early diagnosis of Thyroid eye disease can be difficult and relies on the clinical and radiological tests. A normal thyroid blood test does NOT exclude thyroid eye disease. Early treatment can prevent full blown disease.


Treating the thyroid gland is an important first step to bring the disease under control. Eye treatment begins with the use of tear replacement, ice packs and low dose topical steroids to address the inflammation. All patients should cease smoking. If disease continues, oral steroids, intravenous steroids, steroid sparing immunosuppression or orbital radiotherapy can be used. Low dose orbital radiotherapy provides a safe and effective means for controlling disease involving the orbit and is our intervention of choice. 


When thyroid eye disease is in remission, surgery is available to address disfigurement. This includes repositioning the eyelids, orbital decompression to reposition the eyeball within the eye socket and cosmetic surgery for excess fat bulge. We offer keyhole stereotactic orbital decompression through the nose which is more controlled, safer with less pain and faster recovery.