Thyroid Eye Disease (TED)

What is Thyroid Eye Disease?

Thyroid eye disease (TED), also called Graves' orbitopathy, is a chronic immune-mediated inflammation of the orbit, the bony socket around the eye.^[1] It causes swelling of the eye muscles and orbital fat, and is the most common cause of one-sided or two-sided bulging of the eyes (proptosis) in adults.^{[1, 2]}

Common symptoms

Symptoms range from mild to severe. TED is mild in about 77% of cases, moderate to severe in about 22%, and sight-threatening in about 1%.^[2]

• Eyelid retraction, which gives a staring look
• Swelling and redness of the eyelids and the white of the eye
• Bulging of the eyes (proptosis)
• Double vision (diplopia)
• Pressure, pain or a gritty, dry feeling in the eyes
• Reduced or dimmed vision from pressure on the optic nerve, which is an emergency^[2]

Causes and risk factors

TED is most often seen in people with Graves' hyperthyroidism, and about 25% to 50% of people with Graves' disease have it.^[1] Up to 5% of people with TED have normal or low thyroid function.^[2] The main target of the immune attack is the thyrotropin (TSH) receptor, and antibodies against it are found in more than 95% of patients.^[2]

Known risk factors include smoking, older age, male sex, diabetes, high cholesterol, a longer duration of hyperthyroidism, radioactive iodine treatment and high TSH-receptor antibody levels.^{[2, 3]}

How it is diagnosed and treated conventionally

Doctors assess both how active the inflammation is and how severe the disease is, and the choice of treatment depends on both.^{[2, 3]} Most people develop TED while being treated for hyperthyroidism, so endocrinologists play a key role in diagnosis and in deciding who needs a specialist.^[4]

For mild, active disease, guidelines say that control of risk factors, local treatments and selenium (in areas where selenium is low) are usually enough. For moderate to severe active disease, intravenous glucocorticoids are preferred, often with mycophenolate, and other options include teprotumumab, tocilizumab, rituximab, orbital radiotherapy and later surgery.^[3] Teprotumumab can reduce bulging, but side effects include hearing loss in about 30% of patients and it has a high relapse rate.^[2] Sight-threatening TED needs urgent treatment, sometimes with emergency surgery to decompress the orbit.^[3]

Why Thyroid Eye Disease calls for a whole-person approach

TED involves the immune system, the thyroid, the tissues around the eye and daily life. Treatment is led by endocrinology and ophthalmology, and a multidisciplinary approach and quality-of-life assessment are part of standard care.^[2]

Supportive care addresses the symptoms that are left, such as eye dryness, discomfort, poor sleep and stress. It does not change the immune process in the orbit.

Immune activity and inflammation

TED is driven by inflammation, with swelling of the eye muscles and fat, and activation of orbital fibroblasts, the cells that produce the excess tissue.^{[2, 5]} Controlling this activity is the job of medical treatment.

Thyroid control and smoking

Keeping thyroid function stable and stopping smoking are central parts of care, since both are risk factors.^[3] Anything added to your care must not interfere with thyroid control.

Dry, irritated eyes

Eyelid retraction and bulging make it harder to close the eyes fully, which can leave the surface dry and irritated. Lubricating drops and other local measures are standard care.^{[2, 3]}

Sleep and stress

Living with a visible change in appearance, double vision and an uncertain course can affect sleep and mood. Quality-of-life assessment is part of a good care plan.^[2]

Acupuncture as supportive care in Thyroid Eye Disease

What the research shows

No clinical trials of acupuncture in TED were found in PubMed. Acupuncture cannot be said to help TED itself, and nothing suggests it affects proptosis or double vision.

For the dry-eye symptom, which is common in TED, acupuncture has been studied in people with dry eye disease from other causes. A meta-analysis of 21 trials (1,542 eyes) found improved tear film breakup time, tear production and symptom scores compared with artificial tears alone.^[6] A review of studies in 394 patients reported similar gains and no severe adverse effects.^[7] A meta-analysis of 16 trials combining acupuncture with artificial tears found better tear measures, but no significant difference on one symptom questionnaire.^[8] These results are in dry eye generally, not in TED, and the reviews point out that the effectiveness of acupuncture for dry eye is still debated.^[7]

For symptoms more generally, an individual-patient meta-analysis of 39 trials found acupuncture reduced chronic musculoskeletal, osteoarthritis and headache pain,^[9] and a meta-analysis of 24 trials found acupuncture improved insomnia scores compared with medication, with large differences between studies.^[10] These were not studies of people with TED.

How acupuncture may work

For dry eye, one meta-analysis found acupuncture was associated with lower levels of the inflammatory markers IL-6 and TNF-alpha.^[8] This is a finding from dry eye trials, not TED, and does not show how or whether acupuncture would act on the inflamed tissue behind the eye.

What treatment involves

Treatment uses fine, sterile, single-use needles, usually left in place for about 20 to 40 minutes, with a course of several visits and reassessment. Needling close to the eye carries added risk when the eyes are swollen or protruding, so your practitioner may choose points away from the eye and should know about any eye surgery or double vision first.

Serious problems from acupuncture are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[11] Tell the practitioner first if you take blood thinners, have a bleeding disorder, are pregnant, take immune-suppressing medicines that raise infection risk, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine as supportive care in Thyroid Eye Disease

The Ayurvedic view

TED is a modern diagnosis with no classical Ayurvedic name. In Ayurveda, inflammation, redness and burning of the eyes are generally described as Pitta aggravation, and swelling and heaviness as Kapha, while thyroid conditions are described through the individual's overall constitution and digestion (agni). This is a traditional framework, not a biomedical diagnosis.

Therapies that may be used

Care is individualized and is added only to your medical treatment. Smoking is a recognized risk factor for TED, so avoiding smoking is part of any sensible lifestyle plan.^[2]

• Diet and daily routine, such as regular meals and consistent sleep hours
• Stress-reduction practices such as breathing exercises and gentle yoga
• Traditional eye-care practices, which should only be used with your ophthalmologist's agreement because the eye surface can be damaged

Panchakarma, the traditional cleansing program, is not appropriate during acute illness, pregnancy or frailty. It also needs particular caution with active autoimmune disease and during immune-suppressing treatment, and it is not a treatment for TED.

What the research shows

No studies of Ayurvedic treatment in TED were found, so there is no evidence either way. Ashwagandha, an Ayurvedic herb with reported effects on thyroid hormones, deserves particular caution here. A review reported that it can raise thyroid hormone levels, and another review warned of risks for people with thyroid disorders.^{[12, 13]} It is covered further under herbal safety below.

Herbal medicine as supportive care in Thyroid Eye Disease

Herbs and formulas that have been studied

No clinical trials of herbal medicine in TED were found in PubMed. Research is laboratory-based. A review of preclinical studies found that 11 Chinese medicine compounds inhibited orbital fibroblasts in cell experiments, and three of them (polydatin, curcumin and gypenosides) improved disease in mouse models of TED.^[5] A Chinese formula, Pingmu Decoction, which is used for inactive Graves' ophthalmopathy, reduced orbital fat cell accumulation in a cell study.^[14]

What the research shows

There is no clinical evidence that any herb helps people with TED. The reviewers of the laboratory work concluded that clinical trials with adequate power and sound methods are needed to test dosage, safety and effectiveness.^[5] Findings in cells and mice do not show benefit in patients.

Safety and herb-drug interactions

Herbs can have real effects on thyroid function and on medicines, so they need particular care in TED. A review of ashwagandha reported that it can raise thyroid hormone levels, and another review warned of significant risks in people with thyroid disorders, as well as in pregnancy and in liver or kidney dysfunction, with reported cases of liver injury.^{[12, 13]} Herbs that may stimulate thyroid function are best avoided in people with an overactive thyroid.

Herbs can also interact with other medicines, including bleeding with warfarin and lowered levels of immune-suppressing drugs such as ciclosporin.^[15] People with TED often take steroids, antithyroid drugs or immune-targeting drugs, so every herb needs your prescriber's review first. Herbal and dietary supplements are a recognized cause of liver injury.^[16] In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[17] Herbs should come from tested sources and be prescribed individually.

Selenium, which guidelines mention for mild TED in selenium-deficient areas, is a medical decision and should be discussed with your physician before any supplement is used.^[3]

Translating traditional medicine into modern biological language

This section is interpretation, not equivalence. Chinese medicine would describe TED-type features through patterns such as liver fire rising to the eyes, phlegm and dampness gathering around the eyes, or yin deficiency. Ayurveda would describe Pitta and Kapha imbalance in the eyes.

Researchers study biological ideas that loosely parallel them, such as orbital inflammation, fat expansion and fibrosis, oxidative stress and the IGF-1 and TSH receptor pathways.^{[2, 5]} No study has shown that a traditional pattern matches a specific biological change in TED.

How this care fits with your medical care

Supportive care works alongside your endocrinologist, ophthalmologist and any oculoplastic surgeon. We do not diagnose or manage TED or thyroid disease. For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care.

Please bring your diagnosis, recent thyroid and antibody test results, a full list of medicines and supplements, and notes from your eye specialist. Do not stop or change antithyroid drugs, thyroid hormone, steroids or other prescribed treatment, and do not delay eye appointments, without your prescriber.

When to seek urgent medical care

TED is rarely sight-threatening, but when it is, treatment is urgent.^{[2, 3]}

• Blurred, dim or dull vision, or colors that look faded
• Sudden loss of vision in one or both eyes
• New or rapidly worsening double vision
• Severe eye pain or a rapid increase in bulging
• An eyelid that cannot close, with a painful, cloudy or ulcerated surface
• Rapid heartbeat, tremor, fever or confusion with a known thyroid condition

For any emergency, call 911 or go to the nearest emergency department.