THYROID EYE DISEASE (TED) is usually diagnosed when a few classic signs and symptoms arise. These may include eyelid retraction, proptosis/exophthalmos, extraocular muscle restrictions, and diplopia (Gupta et al, 2009). Unfortunately, these issues generally occur in the later stages of TED, leaving this problem often undiagnosed for far too long. It may be possible to identify TED much earlier by considering it when examining the dry eye patient.
Thyroid disease is a well-established risk factor for dry eye disease (Yang et al, 2024; Qian and Wei, 2022), but the relationship is complicated. Hyperthyroid, hypothyroid, and euthyroid states can all be present alongside TED and resultant dry eye, though autoimmune Graves’ hyperthyroid is by far the most common etiology, present in up to 80% of cases (Gupta et al, 2009).
Dry eye signs found in late-stage TED are primarily due to increased ocular surface exposure from lid retraction and proptosis. This orbitopathy is presumed to be due to activation of orbital fibroblasts by thyroid-stimulating hormone antibodies (Burch et al, 2022). However, inflammatory signs can arise earlier in the disease process. These may include injection and chemosis, especially over the lateral rectus muscles (Gupta et al, 2009). Inflammatory mediators, including various interleukins and tumor necrosis factor, have been found to be higher in patients who have TED (Huang et al, 2012; Lo et al, 2021).
There is evidence to suggest that changes in many ocular structures may occur from abnormal levels of thyroid hormones and antibodies, including lacrimal gland hypotrophy, cornea epithelial metaplasia, and meibomian gland dropout (Lu et al, 2005; Sullivan et al, 2017). In essence, the effects on the ocular surface from thyroid disease of any type may result in the misdiagnosis of primary dry eye, evade attempts at treatment, and distract from the correct diagnosis of the underlying thyroid condition (Lu et al, 2025).
Thyroid disease should be considered in any dry eye patient, but particularly in those who show significant signs of ocular inflammation and/or are resistant to first-line therapies. It is important to note, however, that routine thyroid testing (eg, as ordered by the patient’s primary care physician as part of an annual physical) does not usually include testing for thyroid autoantibodies. A full panel of thyroid hormones and antibody levels (Table 1) is necessary to avoid false-negative conclusions. These can be ordered by the eyecare practitioner or referred out to an endocrinologist or rheumatologist (which may be the better choice if other autoimmune diseases may also be suspected) if preferred.
References
1. Gupta A, Sadeghi PB, Akpek EK. Occult thyroid eye disease in patients presenting with dry eye symptoms. Am J Ophthalmol. 2009;147(5):919-923. doi: 10.1016/j.ajo.2008.12.007
2. Yang K, Wu S, Ke L, et al. Association between potential factors and dry eye disease: A systematic review and meta-analysis. Medicine (Baltimore). 2024;103(52):e41019. doi: 10.1097/MD.0000000000041019
3. Qian L, Wei W. Identified risk factors for dry eye syndrome: A systematic review and meta-analysis. PLoS One. 2022;17(8):e0271267. doi: 10.1371/journal.pone.0271267
4. Burch HB, Perros P, Bednarczuk T, et al. Management of Thyroid Eye Disease: A Consensus Statement by the American Thyroid Association and the European Thyroid Association. Thyroid. 2022;32(12):1439-1470. doi: 10.1089/thy.2022.0251
5. Huang D, Xu N, Song Y, Wang P, Yang H. Inflammatory cytokine profiles in the tears of thyroid-associated ophthalmopathy. Graefes Arch Clin Exp Ophthalmol. 2012;250(4):619-625. doi: 10.1007/s00417-011-1863-x
6. Lo C, Yang M, Rootman D. Natural history of inflammatory and non-inflammatory dry eye in thyroid eye disease. Orbit. 2021;40(5):389-393. doi: 10.1080/01676830.2020.1814352
7. Lu Y, Wan X, Ye H, et al. Clinical characteristics of dry eye patients with thyroid disorders: a cross-sectional study. BMC Ophthalmol. 2025;25(1):229. doi: 10.1186/s12886-025-04084-x
8. Sullivan DA, Rocha EM, Aragona P, et al. TFOS DEWS II Sex, Gender, and Hormones Report. Ocul Surf. 2017;15(3):284-333. doi: 10.1016/j.jtos.2017.04.001