Thyroid eye disease (TED) is an autoimmune condition that affects the eyes. It’s often linked to Graves’ disease, an autoimmune disorder that typically causes hyperthyroidism (an overactive thyroid gland). One of the most noticeable symptoms of TED is eye bulging, also known as proptosis or exophthalmos.

For people with TED, proptosis can be both distressing and physically uncomfortable. Understanding why eye bulging occurs and its connection to thyroid function is important for managing the symptoms and finding appropriate treatment.

In this article, we’ll explain proptosis and its causes. We’ll also explore the risk factors for developing eye bulging and other symptoms that may accompany it. Finally, we’ll discuss how to manage both medical and emotional issues related to TED.

Proptosis: An Overview

Proptosis is a condition in which one or both eyes push forward from their normal position in the eye socket. This occurs in most adults with TED as the tissues and muscles around the eyes become swollen and inflamed due to Graves’ disease. Eye bulging is one of the most common and recognizable symptoms of TED.

In TED, proptosis develops as a result of immune system activity. TED is an autoimmune condition, meaning the body’s immune system mistakenly attacks its own healthy tissues. Here, the immune system targets the muscles, fat, and connective tissue around the eyes. This leads to inflammation and swelling. As these tissues grow larger, they create crowding around the eye socket, forcing the eyes forward. This is what leads to proptosis. The degree of bulging can vary from person to person, depending on the extent of inflammation and tissue growth.

Risk Factors for Proptosis

Certain factors can increase the likelihood of developing proptosis due to TED. Here are some common risk factors:

• Graves’ disease — This autoimmune disorder is the leading cause of TED-related proptosis in adults. Graves’ disease affects the thyroid and often leads to eye problems as the immune system mistakenly targets tissues around the eyes.
• Smoking — Smoking significantly increases the risk of developing severe TED symptoms, including proptosis, and may also reduce the effectiveness of treatments.
• Female sex — According to Cleveland Clinic, TED is more common in women than in men.
• Age — TED is more common in adults aged 40 to 60, though it can occur at any age.
• Uncontrolled thyroid levels — Having poorly managed thyroid hormone levels, whether too high or too low, can raise the risk of TED-related eye symptoms, including proptosis.
• Family history of autoimmune disease — A family history of autoimmune conditions like Graves’ disease or TED can increase your chances of developing proptosis and other TED symptoms.

Other TED Symptoms

In addition to the noticeable bulging of the eyes, people with TED often experience other uncomfortable symptoms. A common issue is dry eyes or irritation, which occurs because your upper eyelids can’t fully close over your eyeballs. This can leave the surface of your eyes exposed, making them feel gritty, sore, or as if something is constantly in your eyes. Some people may also experience excessive tearing (watery eyes) or photosensitivity (sensitivity to light).

Other common symptoms are redness and swelling in and around the eyes, and eyelid retraction — where the upper or lower eyelids pull back, making the eyes appear more prominent.

Although proptosis itself may not cause eye pain, people with TED can experience pain behind their eyes and discomfort with eye movement. Diplopia (double vision) or difficulty focusing on objects are also frequent issues. This occurs when the muscles that control eye movement become thickened and less flexible, making it harder for the eyes to move together.

In severe cases, untreated TED can also affect the optic nerve, which connects the eye to the brain. This can lead to vision loss. Regular checkups are essential to monitor for changes and address any worsening symptoms.

How Is Proptosis Treated?

Treating proptosis in TED focuses on reducing inflammation, relieving discomfort, and preventing further eye damage. Treatment options may vary depending on the severity of symptoms. Following are some common treatments for managing eye bulging in TED.

1. Medications

Your ophthalmology team may consider several medication options for treating proptosis.

• Steroids — These are often used to reduce inflammation and swelling in the tissues behind the eyes. Steroids can help improve symptoms in the short term, but long-term use may lead to side effects, so they’re typically prescribed for limited periods.
• Immunosuppressive drugs — Medications like teprotumumab (Tepezza) specifically target the immune response that causes tissue inflammation in TED. These drugs can help reduce proptosis and improve overall eye appearance and function.

2. Lubricating Eye Drops

Artificial tears or ointments help keep the eyes moist, especially if the eyelids don’t fully close. This reduces dryness and irritation caused by proptosis.

3. Orbital Radiation Therapy

In some cases, low doses of radiation are used to target the inflamed tissues around the eyes. This may help reduce swelling and prevent further tissue damage.

4. Surgery

Surgery may be needed for severe cases of proptosis. Three main surgery types can help treat TED: orbital decompression surgery (which creates more space in the eye socket), eye muscle surgery, and eyelid surgery.

Can Treatment Help Bulging Eyes Return to Normal?

With the right treatment, eye bulging caused by TED can often improve, and in some cases, the eyes may return closer to their normal position. However, full recovery can take time — sometimes years — and the extent of improvement varies. Factors such as how long proptosis has been present and the severity of inflammation play a role in the outcome. Starting treatment early and keeping up with regular follow-ups are key steps for the best possible results.

Living With Proptosis

Eye bulging from TED can be challenging, both physically and emotionally. Changes in appearance can impact a person’s self-esteem and confidence. Moreover, the visible symptoms and unexpected vision changes can lead to feelings of anger, anxiety, or depression. Recognizing that these emotions are normal — and that there are ways to cope with the impact of proptosis — can be an important step toward healing.

Here are some strategies that can help:

• Seek emotional support — Talking with a mental health professional or joining support groups can help you express your feelings and connect with others who are going through similar experiences.
• Focus on eye care — Managing symptoms with TED treatments or surgery can help you feel more comfortable and confident.
• Stay informed — Understanding TED and your treatment options can give you a sense of control. The more you know about managing proptosis, the more empowered you’ll feel to handle the physical and emotional aspects of the condition.

Remember, proptosis is a treatable symptom of TED. With the right care, many people find physical and emotional relief. Talk to your eye specialist or health care provider about additional resources and support to help manage how TED affects your daily life.

Talk With Others Who Understand

On TEDhealthteam, the social network for people living with thyroid eye disease and their loved ones, hundreds of members ask questions, give advice, and share their stories with those who understand life with TED.

Have you been diagnosed with TED? How are you managing the condition medically and emotionally? Share your experience in the comments below, or start a conversation by posting on your Activities page.