Purpose

Thyroid eye disease (TED) is the most prevalent extrathyroidal manifestation associated with Graves’ disease and affects 25-50% of these patients. In those with TED, approximately 85% have hyperthyroidism, 10% have hypothyroidism and about 5% are euthyroid. Euthyroid TED is uncommon and poses unique challenges in terms of diagnosis and management for the oculoplastic surgeon. In this case series we present the clinical course and experience of managing this cohort of patients in a tertiary referral centre.

---

Methods

We conducted a 2-year retrospective review of records at Manchester Royal Eye Hospital from January 2024 to December 2025 to identify patients referred with suspected thyroid eye disease but with normal thyroid function. Demographic information, biochemical tests, smoking status, clinical presentation and management was recorded.

---

Results

Six cases were identified; 4 males and 2 females with age range from 28-59 years (mean 43.5 years). 33% of patients were active smokers. Presenting symptoms included: conjunctival injection, ocular pain, diplopia and proptosis (50% of patients). All patients had normal thyroid function tests (TFTs) and 83% had raised TSH Receptor Antibodies (TRAB). Clinical activity score on presentation ranged from 2-3 with a mode of 2. 1 patient required lacrimal gland biopsy to aid diagnosis. All patients had radiological features of thyroid eye disease. 5 cases required 1 immunosuppression with 2 patients requiring rehabilitative orbital decompression surgery.

---

Conclusion

Our findings challenge the common misconception that TED patients that are clinically euthyroid have a milder disease burden and clinical course. Furthermore, we highlight the importance of recognising thyroid eye symptoms even in the absence of systemic symptoms / dysfunction. These patients are best managed in a multi-disciplinary team requiring immunosuppression and surgical intervention.

---

Additional Authors

First name	Last name	Base Hospital / Institution
Alana	Hesketh	University of Manchester, UK
WenYi	Mah	The Christie NHS Foundation Trust, UK
Shaishav	Dhage	The Christie NHS Foundation Trust, UK
Anne	Cook	Manchester Royal Eye Hospital, UK

↑ Back to top