Kheyali Mondal, B.Optometry

Oculoplasty Optometrist, Dr. Shroff’s Charity Eye Hospital, New Delhi, India



Thyroid Eye Disease (TED) is an immune mediated inflammatory disorder, usually abbreviated as TED, also known as Graves’ orbitopathy or Thyroid associated Orbitopathy. It causes expansion of the orbital muscles and fat from oedema and deposition of glycosaminoglycans and collagen.(1)

Sign and symptoms of TED (14)

  • Movement of the eyeball vertically and horizontally causes pain (Retrobulbar ache)
  • Difficulty in moving the eyes during gazing
  • Inflammation and swelling of the eye causing eye to push forward giving the appearance of bulging (Proptosis)
  • Dryness, itching, burning sensation or ocular irritation
  • Excessive tearing (Epiphora)
  • Diplopia or strabismus
  • Appearance of redness or conjunctival congestion
  • Light sensitivity
  • Dysthyroid Optic neuropathy
  • Feelings of anxiety and depression, loss of confidence due to fluctuations of thyroid hormone and appearance

Epidemiology (2,4,5)

  • Ranges from 51.7 % in the Caucasian population to 34.7% in the Asian population.
  • A prevalence of 28% has been reported in Indian studies among Graves’ disease patients.
  • Age of presentation is usually between 40 and 50 years of age .
  • Occurs more commonly in females; However severe disease found predominantly in males and approximately 4 times> females.
  • Mostly associated with:
    • 90% Grave’s hyperthyroidism
    • 6% Euthyroidism
    • 3% Hashimoto thyroiditis
    • 1% primary hypothyroidism

How to rule out TED (1, 4)

  • Thyroid function tests (T3, T4, and TSH)
  • Thyroid specific antibodies (anti-thyroglobulin, anti-thyroid peroxidase and anti-TSH receptor) which may support the diagnosis, but may be negative, especially in late disease.
  • The level of thyroid stimulating immunoglobulin (TSI) correlates with the development of ophthalmopathy in patients with Graves’ disease.
  • Orbital CT scan
  • MRI imaging

Grading the Severity (3)

There are various grading systems available for marking the severity of Thyroid eye disease(TED), but VISA is the most used for the assessment of TED. VISA  stands for Vision, Inflammation, Strabismus & Appearance, which it was developed by Dolman & Rootman in 2006. In this Scoring criteria more than 4 out 10 clinical activity scores indicate an active disease.


Thyroid eye disease is managed by an ophthalmologist and any underlying thyroid problems will be managed by an endocrinologist.

These are some recommendations listed below so that patients know what to expect in terms of care and management:

  • Diagnose the disease accurately
  • Screen all the patients for early signs and symptoms of TED
  • Advice to stop smoking as smoking increases chance of getting TED

Refer the patient who develop TED to a speciality clinic with extensive experience of managing TED

Figure 1: VISA (Vision, Inflammation, Strabismus, and Appearance) classification form



  1. Dolman P. J. (2012). Evaluating Graves’ orbitopathy. Best practice & research. Clinical endocrinology & metabolism, 26(3), 229–248.
  2. Perros, P., Crombie, A. L., Matthews, J. N., & Kendall-Taylor, P. (1993). Age and gender influence the severity of thyroid-associated ophthalmopathy: a study of 101 patients attending a combined thyroid-eye clinic. Clinical endocrinology, 38(4), 367–372.
  3. Ahn, E. S., & Subramanian, P. S. (2014). Treatment modalities of thyroid related orbitopathy. Indian journal of ophthalmology, 62(10), 999–1002.
  4. Weiler D. L. (2017). Thyroid eye disease: a review. Clinical & experimental optometry, 100(1), 20–25.
  5. Lim, S. L., Lim, A. K., Mumtaz, M., Hussein, E., Wan Bebakar, W. M., & Khir, A. S. (2008). Prevalence, risk factors, and clinical features of thyroid-associated ophthalmopathy in multiethnic Malaysian patients with Graves’ disease. Thyroid : official journal of the American Thyroid Association, 18(12), 1297–1301.

Picture Courtesy

  1. Figure 1:
  2. Thyroid Eye Disease: An Introductory Tutorial and Overview of .June 17, 2023.