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Dryness, burning and eyes that feel "exposed" are common complaints, and they usually come from ordinary dry eye. But in some people the cause is a thyroid disease that also affects the eyes. This page is for people who have a thyroid problem, and for people whose dryness does not improve despite treatment.
What thyroid eye disease is
Thyroid eye disease (also called Graves' orbitopathy) is an autoimmune disease: the immune system mistakenly attacks the tissues around the eye, inside the eye socket (the bony cavity in which the eye sits). The muscles that move the eye and the fatty tissue around it swell.
The disease is particularly common in people with Graves' disease (an overactive thyroid gland), but it can also appear with an underactive thyroid, for example in Hashimoto's disease, and sometimes when the thyroid tests are normal. The disease usually goes through an active, inflammatory phase, followed by a stable phase.
Why it causes dry eyes
Several mechanisms work together:
- Increased exposure: the upper eyelid tends to rise (eyelid retraction), and the eye may bulge forwards. So a larger area of the eye is exposed to the air, and the tears evaporate quickly.
- Incomplete closure: in some people the eyelids do not close fully, mainly during sleep. The lower part of the cornea dries out at night, and in the morning the eyes burn particularly badly.
- Less blinking: infrequent or incomplete blinking spreads the tears less well.
- A change in the tears: the disease may also affect the tear gland and the composition of the tears.
In a study of patients who came because of dry eye symptoms, some were found to have thyroid eye disease that had not been diagnosed before. The practical conclusion is simple: when dryness does not respond to the usual treatment, it is worth considering this direction too.
How it is recognised
Besides dryness and burning, look out for the following signs:
- A "staring" or startled look, with white visible above the iris.
- Eyes that look more prominent, or a change in appearance that others comment on.
- Swollen eyelids, especially in the morning.
- Redness at the sides of the eye.
- Pain or pressure behind the eye, mainly when moving the eyes.
- Double vision, mainly when looking to the sides or upwards.
There are also clues that distinguish ordinary dry eye from dryness linked to the thyroid gland: the symptoms are especially strong in the morning, after a night in which the eye did not close properly; the burning is concentrated in the lower part of the eye; or family members remark that you sleep with your eyes slightly open. If any of these sounds familiar, mention it at the examination.
You do not have to see all the signs. Sometimes dryness and burning are the first sign, and the rest appear only later.
What the eye doctor checks
The examination includes the usual dry eye tests: staining of the cornea with fluorescein (a harmless yellow-orange dye), measurement of tear break-up time, a Schirmer test and examination of the eyelids. Details are on the dry eye testing page. A pattern of damage in the lower part of the cornea can suggest incomplete closure.
In addition, the doctor checks the position of the eyelids, whether they close fully, the movements of the eyes and the degree of bulging. The doctor also checks visual acuity, colour vision, the pupil response and the pressure inside the eye, to make sure the optic nerve has not been affected. When active disease is suspected, the doctor may refer you for blood tests with the endocrinologist and for imaging of the eye socket.
Treatment options
Protecting the surface of the eye
At every stage of the disease, the dryness is treated: preservative-free lubricating drops during the day, a thick gel or ointment at night, and glasses with side shields in the wind. An explanation of choosing drops is on the preservative-free eye drops page. When the eyelids do not close at night, the doctor will explain how to protect the eye during sleep.
Treatments at the clinic
- Punctal plugs: may help when there is also a lack of tears, so that the tears stay on the eye for longer.
- Meibomian gland expression and IPL: when an examination shows that the meibomian glands are blocked and are increasing evaporation.
- Bandage contact lens: in selected cases of damage to the cornea, for a limited period and with follow-up.
Treating the disease itself
When the disease is active and moderate or severe, there are treatments that calm the inflammation in the eye socket, such as steroids and other medicines that act on the immune system. In the stable phase, surgery can be considered to correct bulging of the eye, double vision or the position of the eyelids. These treatments are planned by eye doctors who specialise in the eye socket and eyelids, together with the endocrinologist.
Stopping smoking is a particularly important step: smoking is linked to more severe disease and a poorer response to treatment.
Daily steps that can help
- Use preservative-free lubricating drops regularly, even when your eyes feel relatively good.
- Before sleep, apply a gel or ointment as the doctor has instructed, to protect the cornea if the eyelids do not close fully.
- Sleeping with your head slightly raised may reduce eyelid swelling in the morning.
- Sunglasses with side shields protect against wind, dust and strong light.
- In front of screens, remember to blink fully and take short breaks.
- If you smoke, get help to stop. This is one of the most significant steps within your control.
What to expect over time
Thyroid eye disease usually progresses in phases. In the active phase the symptoms can change from month to month, so follow-up is more frequent. In the stable phase the symptoms usually settle, but some of the changes, such as slight bulging of the eye or a raised eyelid, may remain. Even then the dryness needs regular treatment, because the eye continues to be more exposed than before. Regular follow-up makes it possible to detect a worsening, or a sign of damage to the optic nerve, in time.
Working together with the endocrinologist
The endocrinologist (a doctor who specialises in glands and hormones) is responsible for balancing the thyroid gland, and stable balance is also important for the eyes. Some treatments of the gland itself can affect the eye disease, so it is important that the endocrinologist knows about eye symptoms before a treatment is decided. Do not change the dose of your thyroid medicines yourself; any change is made in coordination with the doctor who prescribed them.
When to see a doctor straight away: reduced vision, colours that look faded, new or worsening double vision, strong pain in or behind the eye, bulging of the eye that increases quickly, or an eye that does not close, with pain and redness. These may indicate pressure on the optic nerve or damage to the cornea, and you should be examined by an eye doctor or at an eye emergency department the same day.
In summary
Dry eyes can be the first sign of thyroid eye disease. If you have a thyroid problem, or your dryness does not improve despite treatment, an examination by a dry eye specialist can identify the mechanism, protect the cornea and direct you to the right treatment together with the endocrinologist.
Want a basic explanation first?For basic information on dry eye: the guide on the Mitzmutz site
Frequently asked questions
Can I have thyroid eye disease when my blood tests are normal?
Yes. The eye disease can appear before the thyroid tests change, when they are already balanced with treatment, and sometimes even when they are normal. So the eye doctor may suspect it on the basis of the examination alone.
Will balancing the thyroid gland cure my eyes?
Balancing the gland is very important, but the eye disease runs its course largely separately. Sometimes the eyes continue to suffer even when the gland is balanced, so separate eye follow-up is needed.
Why is it important to stop smoking?
Smoking is linked to more severe thyroid eye disease and a weaker response to treatment. Stopping smoking is an important step you can take yourself.
Are punctal plugs suitable for me?
When there is a lack of tears, plugs may help keep the eye moist. When the main problem is an eye that does not close properly, the exposure is treated first. The decision is made after an examination.
Home care not enough? We can look into it.
At the dry eye clinic in Haifa we find out what is causing the dryness and build a personal treatment plan.
Sources
- Gupta A, Sadeghi PB, Akpek EK. Occult thyroid eye disease in patients presenting with dry eye symptoms. Am J Ophthalmol. 2009;147(5):919-923.
- Bron AJ, de Paiva CS, Chauhan SK, et al. TFOS DEWS II pathophysiology report. Ocul Surf. 2017;15(3):438-510.
- Akpek EK, Amescua G, Farid M, et al. Dry Eye Syndrome Preferred Practice Pattern®. Ophthalmology. 2019;126(1):P286-P334.
- Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017;15(3):575-628.
The information on this site is general only. It is not medical advice and does not replace an examination by an eye doctor.