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Graves ophthalmopathy - External and Internal Eye
Other Resources UpToDate PubMed

Graves ophthalmopathy - External and Internal Eye

Contributors: Brandon D. Ayres MD, Christopher Rapuano MD, Harvey A. Brown MD, Sunir J. Garg MD, Lauren Patty Daskivich MD, MSHS
Other Resources UpToDate PubMed


Although thyroid eye disease, Graves ophthalmopathy, dysthyroid ophthalmopathy, and Graves disease are all used interchangeably, current preference for the ocular changes that can occur with thyroid disease is to use the term thyroid associated ophthalmopathy (TAO) or orbitopathy. Not only is this more specific, but it covers the fact that TAO can occur despite all testing for thyroid disease being normal. TAO is an autoimmune disorder, and it can involve nearly all the ocular structures. Thus, symptoms are related to which ocular structures are affected. The list of possible presentation symptoms include:
  • Dry eyes
  • Tearing
  • Puffy eyelids
  • Chemosis of the conjunctiva
  • Red, angry-looking eyes (especially overlying the insertions of the rectus muscles)
  • Bulging eyes
  • Diplopia
  • Visual blurring or loss
  • Visual Field loss
  • Dyschromatopsia
  • Photopsia on upgaze
  • Ocular pain and/or pressure
Some 80% of patients with systemic hyperthyroidism develop TAO. TAO affects women 2.5-6 times more frequently than men, just as Graves disease is more prevalent in females. Graves disease is more common in African Americans and Asians compared with whites. Interestingly, when TAO is present in males, it is usually more severe. The usual age range is 30-50 years.


E05.01 – Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm

276177000 – Thyroid eye disease

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

The differential diagnosis for TAO includes:
  • Orbital cellulitis – Onset of proptosis is faster; there is other evidence of infection.
  • Carotid cavernous fistula – Often cranial bruit present.
  • Nonspecific orbital inflammation (orbital pseudotumor) – Ptosis more often than lid retraction, isolated enlargement of lateral rectus muscle.
  • Parinaud syndrome – Globes elevate on doll's head maneuver; no proptosis or injection.
  • Sarcoidosis
  • Ectropion
Again, it is important to remember that just because the testing for thyroid dysfunction is negative, it does not rule out TAO.

Remember also that thickened extraocular muscles can occur with Sarcoidosis, metastases, Lymphoma, amyloid limited to these muscles and AL amyloidosis, and Acromegaly.

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Management Pearls

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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Last Updated:02/06/2020
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Graves ophthalmopathy - External and Internal Eye
A medical illustration showing key findings of Graves ophthalmopathy : Eyelid retraction, Proptosis, Dry eyes, TSH decreased
Clinical image of Graves ophthalmopathy - imageId=1858880. Click to open in gallery.
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