EyeTools Optometry Skills

162: A case of thyroid eye disease?

One of my patients complains of dry and watery eyes, gritty eyes and thinks her eyes are more ‘sticking out’ than in the past. She is 35 years old and denies any general health problems although she has noticed she is losing hair from her head. She is not taking any medicine. What is going on?

Dry eye and bulging eyes with hair loss sound very much like thyroid eye disease (TED) which is sometimes associated with an overactive thyroid gland. An overactive thyroid is also known as Graves disease and the eye problems caused by it as Graves ophthalmopathy. It is also known as thyrotoxicosis

It gets complicated as TED is only sometimes associated with an over-active thyroid (hyperthyroidism) due to Graves’ disease. Graves’ disease is an autoimmune condition that leads to the production of antibodies which stimulate thyroid cells to produce excess thyroid hormone.  Some people with Graves’ disease may also have Hashimoto’s thyroid disease, which is associated with antibodies which reduce thyroid hormone production.

This means a person may have Graves’ disease and have an underactive, normally active, or overactive thyroid hormone production. Around 33% of people with an overactive thyroid gland will develop TED. An overactive thyroid can affect anyone, but it’s about 10 times more common in women than men, and typically happens between 20 and 40 years of age.

Autoimmune thyroid disease is associated with, but not the direct cause of TED. Antibodies are produced which target some of the fibroblasts in eye muscles and/or orbital connective tissue within the ocular orbit. Inflammation causes swelling and/or scarring that is likely to push the eye forward resulting in a bulging appearance. This swelling also causes problems with eye movement which can lead to pain on eye movement and double vision.

Along with dry and watery eyes, staring or bulging eyes pain on eye movement and double vision here are some other eye problems associated with TED:

  • Grittiness
  • Photosensitivity
  • Swelling of one or both upper eyelids
  • Bags under the eyes
  • Redness of the lids and eyes
  • Pain in or behind the eye, especially when looking up, down or sideways
  • Difficulty moving the eyes.

Your patient should be referred to her general practitioner for blood tests to determine levels of circulating thyroid hormones.



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