How thyroid eye disease affects your eyes
Thyroid eye disease (also called Graves’ ophthalmopathy or Graves’ orbitopathy) is an autoimmune condition in which the tissues around the eye become inflamed and swollen. Most people who have it also have an overactive thyroid from Graves’ disease. In a community study in Olmsted County, Minnesota, 90% of 120 people with the condition had Graves’ hyperthyroidism, and the rest had other thyroid conditions or normal thyroid tests.[2]
It is more common in women. In that same county, new cases each year numbered 16.0 per 100,000 women and 2.9 per 100,000 men.[1]
What it does to the front of the eye. The most common sign is eyelid retraction, where the lids pull back and show more of the eye. It was present at some point in 108 of the 120 people in the Olmsted County cohort. About 62% had exophthalmos, where the eyes bulge forward.[2] Both leave more of the cornea exposed to the air, and the lids may not cover it fully during blinks or sleep.
The result is a dry, irritated surface. A 2024 systematic review states that about 85% of people with thyroid eye disease have ocular surface symptoms. It also notes that exposure isn’t the whole story: tear changes and inflammation affect the surface even in people without much bulging.[3][4] People describe grittiness, burning, watering, light sensitivity, and blur.
Pain is common. In the Olmsted County cohort, eye pain was the most frequent symptom when the condition was diagnosed, reported by 30% of people, and some also had watering, light sensitivity, or double vision.[2]
In rare cases, exposure becomes severe enough to damage the cornea. At one eye hospital in India, 13 of 1,000 people treated for thyroid eye disease over about ten years developed a corneal infection. Almost all of the affected eyes had severe lid retraction.[8] Severe exposure needs prompt care from your eye doctor.
How a scleral lens can help
A scleral lens is a large rigid gas-permeable lens. It rests on the sclera (the white of the eye) and arches over the entire cornea without touching it. Before insertion it is filled with sterile, preservative-free saline, which stays over the cornea while the lens is worn.
For an exposed surface, that does three things:
- It keeps the cornea covered and moist. Even if the lids don’t cover the eye fully, the cornea sits under a layer of fluid instead of drying in the air.
- It shields the surface from the lid and the air. The lid slides over the smooth lens rather than a damaged cornea.
- It can sharpen vision. The saline layer smooths out surface damage and irregular astigmatism optically.
Scleral lenses are one of several ways to protect an exposed eye. They work during the day while the lens is in. They don’t change the position of the eye or lids.
What the research shows
Evidence in thyroid eye disease is a single case report. A 2024 systematic review of treatments for surface disease in thyroid eye disease found only 7 qualifying papers. The one about scleral lenses was a single case, and the review concluded that no best practices could be identified from such limited evidence.[3] In that case, a 48-year-old man had had Graves’ eye disease for 13 years, with significant surface damage and over ten diopters of astigmatism, and had never been able to wear contact lenses comfortably. With mini-scleral lenses, his vision improved to 20/25 in both eyes and his eye surface improved.[5]
Studies of exposure from other causes are more encouraging, but small. These studies include people whose cornea is exposed because of lid retraction, facial nerve palsy, or eyelid problems. They are not specific to thyroid eye disease.
- At one university practice, 29 people with exposure keratopathy, lagophthalmos (incomplete lid closure), ectropion, or lid retraction were referred for PROSE (a type of custom scleral lens) after other treatments failed. Eighteen completed the fitting. On average their vision improved from about 20/80 to 20/35, surface damage decreased, and symptom scores improved. The authors suggest PROSE can be an alternative to lid surgery.[6]
- In an oculoplastics clinic over 25 years, lid problems such as lagophthalmos and eyelid malposition sometimes made it harder for the lens to stay centered. In all 27 patients who had eyelid surgery for this, the lens sat better afterward.[7]
Lens and lid care often work together. In the same oculoplastics study, 16 patients whose corneas kept getting worse despite protective lid procedures went on to scleral lens treatment, and 14 of them gained at least one line of vision. Their conditions included facial nerve palsy and neurotrophic keratitis rather than thyroid eye disease.[7] The study suggests lid surgery and scleral lenses can be complementary rather than either-or.
Other options, compared
Surface care in thyroid eye disease usually runs alongside treatment of the disease itself.
| Option | What it does | Typically suited to |
|---|---|---|
| Lubricating drops, gels, and ointment | Supplement the tears and protect the surface | Nearly everyone; ointment often at night |
| Anti-inflammatory and other dry eye treatments | Treat surface inflammation and tear changes | Ongoing irritation despite lubricants |
| Moisture goggles, shields, or taping at night | Reduce overnight exposure | Lids that don’t close fully during sleep |
| Treatments for active thyroid eye disease | Reduce inflammation and swelling around the eye | The active phase, under your doctors’ care |
| Scleral lenses | Hold saline over the cornea during the day | Surface damage or blur not controlled by drops |
| Eyelid surgery or tarsorrhaphy (partly closing the lids) | Improve lid closure and cover the eye | Lid retraction, often once the disease is stable |
| Orbital decompression | Makes room behind the eye so it sits further back | Significant bulging or pressure on the optic nerve |
Questions to ask a scleral lens fitter
- Have you fitted scleral lenses for thyroid eye disease or other causes of exposure?
- Is my disease stable enough for a fit, or should we wait?
- How will you work with my eye doctor and any oculoplastic surgeon?
- If I have lid or orbital surgery later, will the lens need to be refitted?
- How should I protect my eyes overnight?
- What should I do if my eye gets red and painful while wearing the lens?
Common questions
Can scleral lenses treat thyroid eye disease?
No. They protect and moisten the surface of the eye and can improve vision while you wear them. They don't treat the inflammation behind the eye, reduce bulging, or fix double vision. Those are handled by your thyroid doctor, eye doctor, and sometimes an oculoplastic surgeon.
My eyes don't fully close at night. Will a scleral lens help with that?
Not overnight. Scleral lenses are normally removed before sleep. Nighttime exposure is usually managed with ointment, moisture goggles or shields, or lid surgery. Ask your eye doctor what's right for you.
Do I need eyelid or orbital surgery before a scleral lens?
Not necessarily. Some people are fitted without surgery. In an oculoplastics clinic study, lid surgery improved how well the scleral lens sat on the eye in every patient who needed it. Your fitter and surgeon can tell you which order makes sense.
Should I wait until my thyroid eye disease is stable?
Ask your eye doctor. Thyroid eye disease often has an active inflammatory phase followed by a stable phase. If your eye position or lids are still changing, your fitter may need to adjust the lens, and other treatments may be a priority.
Is dry eye in thyroid eye disease just from the eyes bulging?
Not entirely. Exposure plays a part, but research also points to inflammation and changes in the tears, including in people without much bulging. That is one reason dry eye treatments are often used alongside any lens.