Thyroid Eye Disease

A patient with bilateral thyroid eye disease with upper lid retraction
and exophthalmos. There are also bilateral periorbital oedema.



Right unilateral thyroid eye 
disease causing severe 
restriction of the inferior rectus 
and upgaze.Note the lid lag on 
Thyroid eye disease is one of the commonest cases in the final MRCOphth, it is important that you know it well.
It can be presented as a spot diagnosis, orbital examination or ocular motility examination.

Spot diagnosis 

The patient has bilateral (unilateral) exophthalmos with lid retractions. There are also periorbital swellings. 
The diagnosis is thyroid eye disease. 

Look at the neck for thyroid enlargement or thyroidectomy scar (this may be hidden by necklace).

Orbital examination
The patient has bilateral (unilateral) exophthalmos (do not forget to examine the patient from the side and 
above). Exophthalmometer shows reading of _____mm for the right eye and ______mm for the left eye. 
Also mention if the proptosis is axial or non-axial. In thyroid eye disease with severe restriction of the inferior 
rectus, the globe may deviate inferiorly in the primary position. Note: Do not forget other causes of proptosis 
if the problem appears to be unilateral.

Mention that you like to:

  • examine the ocular motility looking for upgaze restriction and lid lag
  • examine the optic nerve function (visual acuity, afferent pupillary reaction, colour vision, fundoscopy 

  • and visual field)
  • examine the patient's thyroid status.

Ocular motility examination.

This patient has bilateral (unilateral) exophthalmos. There is restriction of upgaze in both eyes (this may be 
asymmetrical or only affect one eye). The eyes show lid lag on down-gaze.

As in orbital examination, mention that you like to check the function of the optic nerve and thyroid status.


1. The following is the CT scan of a patient with right proptosis. What does the scan show?

2. What is the thyroid status in a patient with thyroid eye disease?

3. What are the triad of Grave's disease?

4. How would you manage a patient with a right upper lid retraction and an unilateral downward displacement of the globe?

5. Would you be concerned about a patient who complains of sore throat while receiving medical treatment for hyperthryoidism?

Return to the main page