What problems occur with TED?

There are a wide range of problems and, although some may have serious consequences, the majority are minor requiring little or no treatment. The problems may be broadly divided into:

  • Cosmetic, for example retraction of both the upper and lower eyelids (causing a staring appearance) and protuberant eyeballs (exophthalmos or proptosis)

cosmetic-ted

Upper and lower eyelid retraction of right eye

  • Double vision (diplopia) due to limitation of eye movements from inflammation or fibrosis of eye muscles

diplopia-ted

Restriction of eye movement

  • Loss of protection of the front surface of the eye (the cornea) with pain and possibly infection resulting in scarring (which can lead to loss of vision)
  • Optic nerve compression (which may lead to loss of vision)

Patients with TED often suffer uncomfortable, red, congested, watery eyes, which may be associated with lid swelling. Retraction of the lids may in part be due to the protuberant eye, but may occur alone due to contraction or over action of the eyelid muscles. This is a relatively common problem and may affect between 32% and 92% of people.

Protuberance (proptosis) of the eyeballs is almost as common. Usually both eyes are involved (although this may be asymmetrical). The cause of protruding eyes is enlargement of the muscles and the fat pushing the eye forward. This may put pressure on the eye causing a rise in eye pressure and the involvement of the eye muscles may prevent the eye moving properly resulting in double vision. Typically this occurs on looking up, and less commonly on left and right gaze. Loss of protection to the eye surface is usually a combination of proptosis, lid retraction and reduced eye movements. Optic nerve compression is relatively rare, but is an important cause of loss of vision if not treated.

inflamed-lateral-rectus-muscle

Inflamed lateral rectus muscle of left eye

In most cases TED becomes inactive over a period of 3 years. Sometimes it may appear to resolve and then recur before becoming inactive. Problems like eyelid retraction may improve in up to 50% of patients but proptosis and eye movement abnormalities tend to persist.