Bulging eyes (proptosis) happen when swelling or an infection behind the eye pushes it forward. Bulging is the main symptom of thyroid eye disease, also called Graves' eye disease, in which the immune system attacks the muscles and other tissues around the eyes. It is often mild, but it can cause double vision, and in rare cases the swelling presses on the optic nerve and causes vision loss. An eye that newly bulges or hurts to move, with red, swollen lids or a fever, can be orbital cellulitis, a serious infection inside the eye socket, most often from a sinus infection: call 310-828-2010 and come straight in or see another eye doctor; when we're closed, go to an emergency room. Call 911 for sudden loss of vision or sudden double vision. For eyes that slowly start to look more prominent, book a comprehensive eye exam.
Key takeaways
- Eyes look pushed forward when tissue behind them swells, as in thyroid eye disease, or when the eye socket is infected, as in orbital cellulitis.
- Thyroid eye disease, where the immune system attacks tissue around the eyes, is often mild but can cause double vision and, rarely, vision loss.
- An eye that newly bulges or hurts to move, with red, swollen lids or fever, means calling us and coming straight in, or an emergency room when we're closed.
- Sudden loss of vision or sudden double vision means calling 911, even if the symptoms go away.
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What causes bulging eyes?
In thyroid eye disease, the immune system attacks the muscles and other tissues around the eyes, and the swelling behind the eye sockets makes the eyes bulge out. The eyelids can also pull back more than usual or not close all the way.
Infection is another cause, and it is an emergency. Orbital cellulitis is a serious infection of the muscle and fat inside the eye socket. It most often starts from a bacterial sinus infection, and while it can happen at any age, it is more common in children.
| Feature | Thyroid eye disease | Orbital cellulitis |
|---|---|---|
| What it is | The immune system attacks the muscles and tissues around the eyes | A serious infection of the muscle and fat in the eye socket |
| Other signs | Dry or gritty eyes, puffy lids, lids that pull back, double vision, light sensitivity | Pain when moving the eye, double vision, swollen lids, fever |
| Who gets it | People with Graves' disease, sometimes while their thyroid function is normal | Any age, more often children; it most often starts from a sinus infection |
| What to do | Book an eye exam; same-day exam if your vision gets worse (emergency room when we're closed) | Call us at 310-828-2010 and come straight in (or see another eye doctor); emergency room when we're closed |
Thyroid eye disease usually affects both eyes, though you may only notice symptoms in one.
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What are the symptoms of thyroid eye disease?
Bulging eyes are the main symptom, and the National Eye Institute lists these others:
- Dry, gritty, red or irritated eyes
- Puffy eyelids
- Eyelids that pull back more than usual or don't close all the way
- Double vision
- Sensitivity to light
- Eye pain or pressure
- Trouble moving your eyes when you look around
Most people have mild symptoms.
Lids that don't close all the way can dry out the eye overnight, and NEI suggests taping them shut at night to prevent dry eye. Our page on eyelids that don't fully close covers other ways to protect the eye.
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How does Graves' disease affect the eyes?
Graves' disease is an autoimmune disease. The immune system attacks the thyroid, a small gland in the front of your neck, and this leads to hyperthyroidism, when your body makes too much thyroid hormone. About 4 out of 5 cases of hyperthyroidism in the United States are caused by Graves' disease.
Sometimes the immune system also attacks the muscles and other tissues around the eyes. That is Graves' eye disease, also called Graves' ophthalmopathy or thyroid eye disease (TED), and about 1 in 3 people with Graves' disease develop some of these eye problems.
The eyes don't always follow the thyroid's timeline. Eye symptoms can start before or at the same time as the symptoms of hyperthyroidism, they can rarely develop after Graves' disease has been treated, and you can develop the eye disease even if your thyroid function is normal.
You're at higher risk if you smoke, if you have a family history of Graves' disease, or if you have another autoimmune disease such as rheumatoid arthritis. Graves' disease is much more common in women and usually develops before age 40.
Signs of an overactive thyroid include weight loss despite a bigger appetite, a rapid or irregular heartbeat, nervousness, trouble sleeping, shaky hands, sweating or trouble tolerating heat, and an enlarged thyroid gland called a goiter. If you notice these along with changes in your eyes, tell your doctor.
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When are bulging eyes an emergency?
Some symptoms can't wait. Use this as a guide:
| What you notice | What to do |
|---|---|
| Sudden loss of vision in one or both eyes, even if it comes back | Call 911 |
| Sudden double vision | Call 911 |
| Double vision or a droopy eyelid with a pupil that looks different, eye pain or a severe headache | Call 911 |
| Any change in vision with face drooping, arm weakness or trouble speaking | Call 911 |
| An eye that newly bulges or hurts to move, with red, swollen eyelids or a fever, especially after a sinus infection | Call us at 310-828-2010 and come straight in (or see another eye doctor); emergency room when we're closed |
| Severe eye pain with nausea, a headache or halos around lights | Call us at 310-828-2010 right away during office hours; emergency room when we're closed |
| Vision that gets blurrier or dimmer when you have thyroid eye disease | Call us for a same-day exam; emergency room when we're closed |
| A blow to the eye that leaves pain or changed vision | Call us right away for a same-day exam; emergency room when we're closed |
| Eyes that have slowly started to look more prominent, lids that look pulled back, or dry, gritty eyes | Book an eye exam |
Sudden changes in vision, such as blurred vision, double vision or loss of sight in one or both eyes, can be signs of a stroke. Call 911 for sudden loss of sight, sudden double vision, or any change in vision with face drooping, arm weakness or trouble speaking. The American Stroke Association says to call 911 even if the symptoms go away, and to check the time so you'll know when the first symptoms appeared. For sudden blur on its own, call us and come in for an exam if it clears right away, or go to an emergency room if it doesn't.
StatPearls calls orbital cellulitis an ocular emergency. Its clearest signs are pain when the eye moves, a bulging eye, and eye muscles that don't move normally with double vision, and its complications include vision loss and spread of the infection inside the skull.
Worsening vision with thyroid eye disease needs a same-day exam, or an emergency room when we're closed, because in rare cases the swelling presses on the optic nerve, the nerve that connects the eye to the brain, and causes vision loss. Our hours are Monday 10 to 5 and Tuesday through Friday 8 to 5; call 310-828-2010 first, and see our urgent eye care page for how same-day visits work.
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How is thyroid eye disease diagnosed?
An eye doctor can check for it with a physical eye exam, taking a close look at your eyes and eyelids. If your eye doctor thinks you may have Graves' disease, you'll need blood tests to check whether your thyroid is working correctly.
Those tests measure your thyroid hormone levels and can check for thyroid-stimulating immunoglobulin (TSI), an antibody your immune system makes in Graves' disease that attaches to thyroid cells.
At a comprehensive eye exam we also check how your eyes line up and move together, your eye pressure, the optic nerve, and the lids and tear film. OCT imaging and visual field testing add a record of the optic nerve that later visits are compared against.
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How is thyroid eye disease treated?
Treating the thyroid sometimes helps the eyes, but people often need separate treatments for their eye problems.
Eye comfort
Artificial tears are the most common treatment for dry or irritated eyes, and you can buy them without a prescription; over-the-counter gels and ointments may also help. Sunglasses help with light sensitivity.
Medicines
If there's a lot of swelling behind your eyes, a doctor may prescribe steroids such as prednisone, or other medicines such as rituximab, to help reduce it.
Tepezza (teprotumumab) is a medicine made for thyroid eye disease. Its FDA label says it is indicated for thyroid eye disease regardless of how active the disease is or how long you've had it, and it is given as a series of infusions into a vein. It is an antibody that blocks a receptor called IGF-1R (the insulin-like growth factor-1 receptor).
The most common side effects listed on the label include muscle spasms, nausea, hair loss, diarrhea, fatigue, high blood sugar, hearing problems, dry skin, changes in taste, headache, weight loss and nail problems. The label also warns about infusion reactions; inflammatory bowel disease, which it can make worse and which has been reported in some people never diagnosed with it before; high blood sugar; and severe hearing problems, including hearing loss that may be permanent in some cases. Encephalopathy, a disease affecting the brain, has been reported since Tepezza came on the market, and the label says Tepezza may harm an unborn baby.
Glasses, surgery and radiation
Special prescription lenses called a prism prescription can help with double vision. If the disease affects your vision, a doctor may recommend a surgery called orbital decompression, and eyelid surgery may be advised if the lids are pulling back too much. In some cases, doctors treat it with radiation.
Tell your thyroid doctor about any eye symptoms, because radioiodine therapy, a common treatment for an overactive thyroid, may worsen Graves' eye disease.
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How we help with bulging eyes at Cohenmehr Optometry
Our optometrists in Los Angeles start with a full exam and imaging, so later changes in the optic nerve or the surface of the eye can be measured against a baseline.
For double vision, we fit prism lenses that merge the two images, as we do in strabismus care. When the images can't be fused, an occluder contact lens, one of our custom soft lenses, switches one of them off.
For eyes that dry out because the lids don't close, we use nighttime gels, ointments or moisture protection, and for severe exposure, scleral lenses that keep the surface bathed in fluid.
We don't perform surgery. When eye muscle or eyelid surgery is the right step, we co-manage it with the surgeon, with your care before and after here.
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Questions patients ask
Can bulging eyes go back to normal?
Sometimes. Graves' eye disease is often mild and may go away on its own, and its symptoms usually last 1 to 2 years. It often improves with treatment or even resolves on its own, but it can come back or get worse. If the bulging stays, treatment for severe cases can include medicines that reduce the body's immune response and surgery to improve bulging eyes or correct changes to your vision.
Does smoking make thyroid eye disease worse?
Yes. Smoking makes Graves' eye disease worse, and NEI calls quitting the most important lifestyle change you can make. Smoking also raises the risk of eye problems in the first place for people with Graves' disease. NIDDK lists it, along with stressful life events, as a trigger that can make the eye disease come back or get worse, and advises anyone who smokes or uses other tobacco products to stop.
Can thyroid eye disease cause blurry vision?
Yes. NIDDK lists blurred or double vision among the symptoms of Graves' eye disease. In rare cases, swelling around the eyes presses on the optic nerve and causes vision loss, so vision that keeps getting worse needs a same-day exam (an emergency room when we're closed), and sudden loss of vision needs a call to 911. Bring up any blur at your eye exam, even if it seems minor.
Can thyroid eye disease make your eyelids puffy?
Yes. Puffy eyelids are one of the symptoms of Graves' eye disease, and NEI suggests raising the head of your bed so your head is higher than your body while you sleep. Eyelids that newly turn red and swollen, especially with a sinus infection, can mean an infection around the eye: call us at 310-828-2010 the same day. If you also have a fever, or the eye starts to bulge or hurts to move, call and come straight in, or see another eye doctor. When we're closed, go to an emergency room for any of these.
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Sources
- National Eye Institute: Graves' eye disease
- NIDDK: Graves' disease
- DailyMed: Tepezza (teprotumumab-trbw) prescribing information
- StatPearls: Orbital cellulitis
- American Stroke Association: Stroke symptoms
- National Library of Medicine (MeSH): Brain diseases
Written by
Dr. Kevin Cohenmehr, OD
Medical eye care: glaucoma, diabetic eye exams, macular degeneration and eye infections, plus vision therapy for children. A graduate of UCLA and SUNY College of Optometry.
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