Graves Disease Linked With Adverse Corneal Outcomes, Orbitopathy Status Irrelevant

Bulging eye (exophthalmos) due to thyrotoxicosis
Eye in thyrotoxicosis. A woman’s bulging eye (exophthalmos) due to thyrotoxicosis. The eyeball on the right is pushed forwards relative to the normal eye, giving a staring appearance. Exophthalmos is most often caused by thyrotoxicosis (over-activity of the thyroid gland). Swelling of soft tissue in the eye socket pushes the eye forwards, restricting movement and causing double vision. Treatment of the underlying thyroid disorder may relieve the condition, but sometimes surgery to relieve pressure in the eyeball may be required.
Regular ocular surface assessments are essential for patients with Graves Disease, even without the clinical manifestations accompanying orbitopathy.

Graves disease (GD) is associated with dry eye disease (DED) and corneal epithelial thinning, regardless of the presence of Graves orbitopathy (GO), according to a study published in Cornea.

Researchers included 58 eyes of 58 patients in an observational study to assess ocular surface parameters in patients with GD, both with and without GO. They included a healthy control group (n=24, mean age 41.00±13.65 years) and patients with GD, who were further stratified into subgroups consisting of participants with GO (n=18, mean age 44.44±13.95 years) and patients without GO (n=16, mean age 45.75±10.59 years). All patients with GO had proptosis and inactive disease (mean clinical activity score: 1.33±0.69).

Researchers found that patients with GD (both with and without GO) had a higher, statistically significant percentage of clinical diagnosis of DED (77.7% vs 4.17% for GO vs controls and 75.00% vs 4.17% for non-GO vs. controls; P <.001 for both). However, they found no significant difference between GD patients with and without GO (P =.07). They also noted higher Ocular Surface Disease Index (OSDI) scores (15.44, 15.06, 9.88) and lower tear breakup time (TBUT) measurements (6.33 s, 7.25 s, 11.63 s) in the GO, GD without GO, and control groups, respectively. Corneal epithelial thickness (CET) was higher in the control group compared with patients with GD, particularly in the superior paracentral, temporal superior paracentral, and nasal superior paracentral octans (P =.03, P =.04, and P =.02, respectively). They noted no significant differences between subgroups of patients with GD (P >.05). 

“These results alert to the importance of a regular ophthalmologic examination, including ocular surface and CET assessment, in the evaluation of patients with GD regardless of the presence of GO,” according to the investigators. “Prompt therapeutical measures targeting the ocular surface may be useful to prevent the development of DED symptoms and corneal damage in these patients and should be provided early in disease course.”

Study limitations include a limited sample size, a lack of comparative analysis in patients with active GO, and insufficient CET measurement in the perilimbal zone.


Carreira AR, Rodrigues-Barros S, Moraes F, et al. Impact of Graves disease on ocular surface and corneal epithelial thickness in patients with and without Graves orbitopathy. Cornea. 2022;41(4):443-449. doi:10.1097/ICO.0000000000002753