Summary
Thyroid eye disease (TED) is an autoimmune inflammation of the eye-socket tissues, most commonly seen in patients with Graves’ disease. It causes the eye to bulge forward, the eyelids to retract, the eye to be red and swollen, and (in severe cases) double vision and loss of vision from optic-nerve compression.
I lead the regional service for orbital decompression at Portsmouth Hospitals University NHS Trust, and manage TED across all stages, in close collaboration with endocrinology and orthoptic colleagues.
Who is this for?
I see patients across the full TED pathway:
- newly diagnosed patients with mild–moderate inflammation,
- those with active disease being considered for steroids or immunomodulation,
- patients with sight-threatening optic-nerve compression needing urgent decompression,
- patients in the rehabilitation phase requiring decompression, squint or eyelid surgery,
- patients with stable disease and persistent eyelid retraction (the ‘staring’ appearance).
What the procedure involves
Treatment is staged across the disease cycle:
- Active phase: smoking cessation, selenium, lubrication, and (where indicated) intravenous steroids or immunomodulation, in close partnership with endocrinology.
- Orbital decompression: surgical removal of bone (medial wall, floor, and/or lateral wall) and fat to give the eye room to recede. Performed via a hidden incision and/or transconjunctival approach.
- Squint (strabismus) surgery: for stable double vision, in collaboration with strabismus colleagues.
- Eyelid surgery: including upper- and lower-lid recession to address eyelid retraction, and blepharoplasty for residual fullness.
The order is important. Decompression is performed first, then squint surgery, then eyelid surgery, because each can affect the next.
Recovery and what to expect
- Decompression: overnight stay, marked bruising and swelling for 1–2 weeks, full recovery over 6–8 weeks.
- Eyelid recession: day case, 1–2 weeks of swelling.
- Most patients describe a transformative improvement in both comfort and appearance.
Risks and alternatives
Decompression is a major operation. Risks include bleeding, infection, sinus problems, double vision (around 20–30% of patients require subsequent squint surgery), numbness of the cheek, and very rarely loss of vision.
Non-surgical alternatives (lubrication, prisms, botulinum toxin to the upper-lid retractor) have a role in mild cases and as bridging measures.