Abstinence
The eyes seem to protrude forward, more protein is visible than before.
CONDITION / FACE
Endocrine ophthalmopathy.
Endocrine ophthalmopathy is an inflammation of the tissues of the eye socket, most often with Graves' disease: the eyes protrude, the eyelids tighten, dryness and double vision appear. While the inflammation is active, she is treated by an endocrinologist and an ophthalmologist; operations are done when it has subsided.
CONCEPTUAL VISUALIZATION- What it is
- Inflammation of the tissues of the eye socket: the eye muscles and fat behind the eye swell.
- How common
- Eye problems occur in about 1 in 4 people with hyperthyroidism due to Graves' disease.
- run over
- 77% have a mild form, 22% have a moderate or severe form, and 1% have vision impairment.
- Who treats it
- Active phase — endocrinologist and ophthalmologist; consequences after it — a surgeon.
01 / WHAT IS ITWhat is
What is
endocrine ophthalmopathy.
Endocrine ophthalmopathy—also called Graves' orbitopathy—is the main manifestation of Graves' disease outside the thyroid gland. Due to immune inflammation, the muscles that move the eye and the fat behind the eye swell.
Therefore, the eye protrudes forward (protrusion, or exophthalmos), the eyelids tighten, swell and redden, and double vision appears. In severe cases, swollen tissues compress the optic nerve.
The disease goes through an active phase, when inflammation continues, and an inactive phase, when it subsides, and the changes remain. The treatment depends on this: the active phase is treated with drugs, and restorative operations — decompression of the orbit, operations on the eye muscles and eyelids — are performed in the inactive phase.
Most people with ophthalmopathy have hyperthyroidism, but up to 5% have normal or even reduced thyroid function.
This is general information. The doctor will tell you what will suit you after the examination.
02 / SIGNSHow
How
ophthalmopathy presents.
The changes occur in one or both eyes, and their severity varies greatly from person to person: in most cases, the form is mild.
"Widely open" eyes
The upper eyelid is pulled up, the lower one is lowered. Eyelid retraction is the most frequent manifestation of ophthalmopathy.
Retraction of the eyelidDryness and grains of sand
The eyes are dry, as if there is sand in them, they water, they hurt from bright light.
Swelling and redness
The eyelids and the white of the eye are swollen and red - this is often what active inflammation looks like.
Doubling
Swollen muscles move the eye worse, and objects become double.
Deterioration of vision
Vision is blurred, colors fade - a possible sign of compression of the optic nerve, which should be treated urgently.
03 / REASONSWhy does it occur?
Why does it occur?
ophthalmopathy
It is an autoimmune disease: it is associated with antibodies to the thyroid-stimulating hormone (TSH) receptor. Some of the risk factors can be changed.
Graves' disease
Most often, eye problems appear when a person is already being treated for hyperthyroidism by an endocrinologist.
Smoking
The main factor that can be influenced. Among people with Graves' disease, smokers were twice as likely to have ophthalmopathy (odds ratio 2.00), and quitters had a lower risk, according to a meta-analysis of 22 studies.
Hormones and antibodies
An impaired thyroid function and a high level of antibodies to the TSH receptor increase the risk.
radio iodine
Treatment of hyperthyroidism with radioactive iodine is also a risk factor, therefore, if necessary, it is combined with a preventive course of prednisolone.
Other
Male gender, older age, diabetes and high cholesterol.
04 / SEEK MEDICAL ADVICE
When to seek medical advice?
Ophthalmopathy mostly develops gradually, it is treated as planned, but under the supervision of an endocrinologist and an ophthalmologist. The most dangerous complication is compression of the optic nerve by swollen muscles (compressive optic neuropathy). It happens infrequently — according to various reports, from 1 to 8% of patients — but it must be treated urgently to save vision.
103 immediately if:
- suddenly stopped seeing in one or both eyes;
- severe pain in the eye, especially if it started suddenly;
- the child's eye suddenly began to protrude.
Do not delay a visit to the doctor:
Immediately — to the reception department or 103: the eyes have just, in the last hours or days, started to bulge and at the same time the vision has changed or there is a severe headache or nausea. On the same day - to the ophthalmologist: wavy lines or flashes in front of the eyes, blurred vision, worse vision in one eye, dull colors, sudden double vision or pain in the eye with double vision. These may be early signs of optic nerve compression. In the coming days: you noticed that the eyes are gradually bulging, the appearance of the eyelids has changed, dryness, photophobia or lacrimation have appeared - to an endocrinologist or family doctor: an early examination by a specialized specialist is important for almost all patients. Planned: the inflammation has subsided, and the drooping, double or drooping eyelids have remained, a consultation on reconstructive operations.
05 / DIAGNOSTICSHow to determine
How to determine
phase and severity.
- Endocrinologist
Thyroid hormones and antibodies to the TSH receptor; treatment of hyperthyroidism.
- Activity
The ophthalmologist evaluates whether the inflammation continues: pain, redness and swelling of the eyelids and the white of the eye.
- Severity
How much the eyes protrude (measured in millimeters), whether there is double vision, how the eyelids close.
- Optic nerve
Acuity and color vision, reaction of the pupils, fields of vision; A CT scan or MRI will show if the nerve is compressed.
06 / TREATMENTHow we treat
How we treat
ophthalmopathy
Treatment depends on whether the inflammation continues and how severe the changes are. The active phase is treated with drugs by an endocrinologist and an ophthalmologist, restorative operations are performed when the inflammation subsides. The exception is a threat to vision: then the operation is performed urgently.
01
For everyone
What can you do yourself?
- Quit smoking
- A systematic review provided strong evidence that smoking causes ophthalmopathy; in smokers, the disease progresses more often, and the treatment gives a worse result.
- Stable hormones
- Dysfunction of the thyroid gland is a risk factor, so it is important to be treated by an endocrinologist and keep hormones in the normal range.
- Eye protection
- Moisturizing drops, gels or ointments, dark glasses in bright light; sleep with the head raised on the pillows; glasses instead of contact lenses.
02
Active phase
Led by an endocrinologist together with an ophthalmologist.
- Light form
- It is usually enough to eliminate the risk factors and treat the eyes locally; in regions where selenium is lacking, selenium is added. In a study of 159 patients, selenium improved quality of life and slowed progression. The mild form often passes: in the observation of 43 patients with a mild inactive form, complete remission occurred in 58.1%.
- Moderate and severe form
- According to the EUGOGO guidelines, intravenous glucocorticoids work better and are easier to tolerate than tablets. The American-European consensus, where available, prioritizes teprotumumab; but it is expensive, often relapses, and hearing loss occurs in 30% of patients.
03
Vision threat
Compressive optic neuropathy.
- What it is
- More than 90% of cases are compression of the optic nerve by swollen eye muscles.
- Treatment
- High doses of intravenous glucocorticoids; if they do not help - urgent decompression of the orbit. According to a meta-analysis of 17 studies, decompression alone or in combination with glucocorticoids may improve vision better than glucocorticoids alone, but the evidence is still limited.
- Forecast
- If neuropathy is detected and treated in time, vision is restored in most cases.
04
Inactive phase
Restoration operations are in a certain sequence.
- order
- Orbital decompression is usually performed first, then an operation on the eye muscles (for diplopia), and finally on the eyelids.
- Decompression of the orbit
- Part of the orbital wall or fat is removed to move the eye back. In a meta-analysis of 87 studies (5,102 patients), protrusion decreased by an average of 3.46–5.80 mm depending on the method, and new diplopia occurred in about 11%. Numbness after decompression of the outer wall in various studies — from 12 to 50%.
- Eyelids
- After decompression, the tightened upper eyelid hardly ever descends, so separate eyelid surgery is usually required. There are several time-tested methods for retraction; the lower eyelid is lengthened with a spacer made of own tissues or biomaterial.
07 / AT THE VALIKHNOVSKYI INSTITUTE
How
How
we treat it.
At Dr. Valikhnovskyi's Institute of Surgery, endocrine ophthalmopathy is treated in the "New Face" direction. The clinic is responsible for its part - operations on the eyelids, when the inflammation has subsided. The active phase, hormones and condition of the optic nerve are managed by an endocrinologist and an ophthalmologist, and the operation is planned taking into account their conclusions.
CLINIC SERVICE
A new face
Form, symmetry, facial expressions and functions after injuries, wounds, burns, removal of tumors and congenital changes.
View service
What we do for this condition
- Correction of retraction of the upper eyelid - the tightened eyelid is lowered so that the eyes do not look "wide open" and close better.
- Spacers and grafts for the lower eyelid - lengthen the lower eyelid so that it rises and covers the white of the eye.
- Canthopexy and canthoplasty - strengthen or restore the outer corner of the eye so that the lower eyelid fits tightly to the eye.
- Blepharoplasty — removes excess skin and fat on the eyelids after the inflammation subsides.
- Correction of a drooping eyelid — if, on the contrary, the eyelid has drooped during ophthalmopathy.
Rostislav Valikhnovskyi
Plastic surgeon, candidate of medical sciences, founder of Dr. Valikhnovskyi Institute of Surgery.
How treatment works with us
- Photos and reviews onlineSend a photo of the eyes directly and from the side and the conclusions of an endocrinologist and an ophthalmologist - the doctor will pre-evaluate the situation.
- ConsultationExamination of the eyelids and the position of the eyes; whether the inflammation subsided - according to the ophthalmologist's opinion.
- PlanWhat to fix and in what sequence; whether orbital decompression or eye muscle surgery is required first.
- SurgeryOn the eyelids - in the inactive phase, the reception is selected under the upper or lower eyelid.
- RecoveryThe first days — swelling; the doctor will explain care and when to come for an examination. Thyroid disease is still managed by an endocrinologist.
08 / QUESTIONS AND ANSWERSCommon
Common
questions
Short answers. What is right for you, the doctor will tell you during the consultation.
Can ophthalmopathy go away by itself?
The mild form often passes: in the observation of 43 patients with a mild inactive form, complete remission occurred in 58.1% in 18 months. Moderate and severe require treatment.
Why is the operation not done immediately?
As long as the inflammation is active, it is treated with drugs, and restorative operations are indicated when it has subsided. The exception is a threat to vision: then decompression of the orbit is done urgently.
Will quitting smoking help?
Yes. Smoking causes ophthalmopathy and worsens treatment outcomes, and quitters have a lower risk than smokers.
Will my eyes go back to normal when I heal my thyroid?
Mild symptoms often improve with treatment for hyperthyroidism, but some people still have eye problems. Prolapse that did not go away after other treatment is corrected by surgery.
What is orbital decompression?
An operation in which part of the bony walls of the orbit or fat is removed to move the eye back. Depending on the method, the protrusion decreased by an average of 3.46–5.80 mm.
Will the eyelids fall into place after decompression?
Mostly no: according to a meta-analysis, the upper eyelid hardly ever descends after decompression. Therefore, eyelid surgery is usually done separately.
Who treats endocrine ophthalmopathy?
Hormones and the active phase — an endocrinologist, the condition of the eyes and optic nerve — an ophthalmologist. Restorative operations in the inactive phase — surgeons, in particular on the eyelids.
Sources
18 sources · EUGOGO and ATA/ETA guidelines, systematic reviews, meta-analyses and NHSshowCollapse
- The 2021 European Group on Graves' orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves' orbitopathyEuropean Journal of Endocrinology, 2021doi:10.1530/EJE-21-0479 ↗
- Management of Thyroid Eye Disease: A Consensus Statement by the American Thyroid Association and the European Thyroid AssociationThyroid, 2022doi:10.1089/thy.2022.0251 ↗
- Comparison of the 2021 EUGOGO guidelines and the 2022 ATA/ETA consensus statement for the management of Graves' orbitopathyEuropean Thyroid Journal, 2025doi:10.1530/ETJ-25-0318 ↗
- Thyroid eye disease (Graves' orbitopathy): clinical presentation, epidemiology, pathogenesis, and managementThe Lancet Diabetes & Endocrinology, 2025doi:10.1016/S2213-8587(25)00066-X ↗
- Prevalence and natural history of Graves' orbitopathy in a large series of patients with newly diagnosed graves' hyperthyroidism seen at a single centerJournal of Clinical Endocrinology and Metabolism, 2013doi:10.1210/jc.2012-3873 ↗
- Cigarette smoking and thyroid eye disease: a systematic reviewEye, 2007doi:10.1038/sj.eye.6702603 ↗
- Risk factors for graves' orbitopathy: A systematic review and meta-analysisEuropean Journal of Ophthalmology, 2026doi:10.1177/11206721261470209 ↗
- Selenium and the course of mild Graves' orbitopathyNew England Journal of Medicine, 2011doi:10.1056/NEJMoa1012985 ↗
- Orbital decompression for thyroid eye disease: methods, outcomes, and complicationsEye, 2018doi:10.1038/eye.2017.260 ↗
- Comparative effectiveness of various orbital decompression techniques in treating thyroid-associated ophthalmopathy: a systematic review and meta-analysisBMC Ophthalmology, 2024doi:10.1186/s12886-024-03749-3 ↗
- Outcomes of Patients With Dysthyroid Optic Neuropathy Treated With Intravenous Corticosteroids and/or Orbital Decompression Surgery: A Systematic Review and Meta-analysisJournal of Clinical Endocrinology and Metabolism, 2023doi:10.1210/clinem/dgad211 ↗
- Dysthyroid optic neuropathy: evaluation and managementJournal of Endocrinological Investigation, 2021doi:10.1007/s40618-020-01361-y ↗
- Eyelid Surgery in Thyroid Eye DiseaseOphthalmic Plastic and Reconstructive Surgery, 2023doi:10.1097/IOP.0000000000002543 ↗
- Graves Lower Eyelid RetractionOphthalmic Plastic and Reconstructive Surgery, 2016doi:10.1097/IOP.0000000000000613 ↗
- Influence of orbital decompression on upper eyelid retraction in Graves' orbitopathy: a systematic review and meta-analysisOrbit, 2024doi:10.1080/01676830.2023.2248621 ↗
- Bulging eyes (exophthalmos)NHS, 2026nhs.uk/symptoms/bulging-eyes ↗
- Overactive thyroid (hyperthyroidism): complicationsNHS, 2023nhs.uk/conditions/overactive-thyroid-hyperthyroidism/complications ↗
- Vision lossNHS, 2025nhs.uk/conditions/vision-loss ↗
The figures on the page are from these sources.
The eyes have changed
after thyroid disease?
Send a photo of the eyes and the conclusions of an endocrinologist and an ophthalmologist. The doctor will tell you what can be corrected on the eyelids and when.