Surgery for Thyroid Eye Disease

Thyroid eye disease (TED) is a chronic (long-term) disease that can lead to progressive damage to the tissues in and around the eyes. This means that damage gets worse over time. TED progresses in phases, with an inflammatory active phase and an inactive phase.1,2

Surgery is sometimes used to correct the damage that TED can cause, such as scarring to the muscles and tissues around the eye. Surgery is not performed in the active phase because inflammation and damage may still occur.3

Once TED reaches the inactive phase, a TED specialist will decide if surgery is needed. Multiple surgeries are usually needed to correct the damage caused by TED.3

Phases of TED

There are 2 phases of TED: an active (acute) phase and inactive (chronic) phase. The treatment goal for the active phase is to reduce inflammation. Goals of the inactive phase are to return function and repair cosmetic damage done in the active phase.2

Active phase

The active phase results in inflammation and occurs when the body mistakes healthy tissue for harmful invaders. As a result, the body’s own immune system attacks the tissue in and around the eye. This causes symptoms of TED, including:1,2

  • Swollen, puffy, red eyes and eyelids
  • Dry, gritty eyes
  • Bulging eyes that look like you are staring
  • Eyelids pulling back (retraction and lateral flare)
  • Double vision (diplopia, dip-low-pee-uh)
  • Misaligned eyes that do not line up and point in different directions (strabismus, struh-biz-mis)
  • Sensitivity to light
  • Eye pressure or pain

Inactive phase

In the inactive or chronic stage, disease progression stops. However, symptoms often remain. Those in the inactive phase of TED may have scar tissue or problems with vision in this phase depending on the severity and length of time of the active phase.2

If left untreated, scar tissue from the active phase can continue to damage the eyes.3

Who needs TED surgery?

A TED specialist will decide if surgery is needed for those with thyroid eye disease in the inactive phase. This specialized eye surgeon considers many factors when planning surgery, including:4

  • Goals
  • Type of surgery
  • Each person’s severity of symptoms

In general, those who may benefit from surgery include those who want improved appearance and function of their eyes and face.4

Thyroid eye disease surgeries

TED surgeries are usually done in a specific order:3

  • Orbital decompression
  • Double vision surgery
  • Eyelid repair

Orbital decompression

This minimally invasive procedure is used to relieve proptosis (prop-toe-sis), or bulging eyes. In this procedure, the surgeon removes some of the fat and bones in the eye socket that have been damaged by TED. The surgeon then reconstructs and repositions the eye to a normal position.4

Double vision (strabismus) surgery

TED can cause misalignment of the eyes and lead to double vision. Misalignment of the eyes is known as strabismus. This occurs because of damage to the muscles that attach to the eyes. Surgery may be needed to repair these muscles to realign the eyes. This moves the muscles around your eye so they point in the same direction again and allows for normal vision.3,5

This procedure is performed by a TED specialist eye surgeon and involves detaching, tightening, and reattaching the eye muscles.3,5

Eyelid repair (eyelid retraction) surgery

TED can lead to eyelid retraction, or pulling back on the skin of the eyelid. When this happens, it is difficult or impossible to blink or close your eyes. This is caused by both swelling and tightening of the muscles and tissues around the eye. Eyelid repair surgery may be needed to release the tight tissues and muscles around the eyelid. Eyelid repair surgery allows your eyelids to return to their natural shape and position.1,6

Surgical repair for TED is common and happens after the active phase. It may be hard to know if you are moving from the active phase to the inactive phase. To help track the severity of your symptoms, take selfie photos in natural light often. Tracking your symptoms in a journal can also help to show your TED specialist changes in symptoms over time.

As always, talk to your TED specialist and get care for TED as soon as possible. Outcomes of TED are better for those who get treatment early and complications like vision loss occur less often.3

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Written by: Katie Murphy | Last reviewed: October 2021