Purpose

Dry eye disease (DED) is a complication of thyroid eye disease (TED), yet its specific phenotypic profile remains poorly characterized. This study aimed to define the ocular surface features of TED in Graves’ Disease (GD), with and without TED, versus healthy controls.

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Methods

In this cross-sectional study, 160 consecutive GD patients (101 with TED, 59 without TED) and 67 matched healthy controls underwent a comprehensive ocular surface workup, including Ocular Surface Disease Index (OSDI), noninvasive breakup time (NIBUT), tear meniscus height (TMH), meiboscore and bulbar redness. TED patients were stratified by activity (Clinical Activity Score, CAS) and severity. DED was defined as OSDI ≥13 plus abnormal NIBUT or TMH.

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Results

DED was present in 102/160 GD patients, more prevalent than in controls (OR 6.65; P<0.0001), in TED than GD without TED (OR 2.82; P=0.004), and in moderate-to-severe active than mild TED (OR 3.53; P=0.01). The OSDI score was significantly higher in moderate-to-severe active TED than in all other groups (all P<0.0001), and higher in mild TED than in GD without TED (P=0.001). Meiboscore was elevated in all GD subgroups vs controls (all P≤0.01); NIBUT showed a stepwise reduction, lowest in moderate-to-severe active TED. TMH was paradoxically elevated, peaking in moderate-to-severe active TED. TMH and redness correlated with CAS (P<0.0001) and independently predicted active TED (P=0.0009).

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Conclusion

TED shows ocular surface features that combine reduced tear film stability, meibomian gland dysfunction and paradoxical hyperlacrimation. This pattern is consistent with an evaporative DED phenotype in which increased TMH reflects reflex tearing rather than true tear sufficiency.

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Additional Authors

First name	Last name	Base Hospital / Institution
Filippo	Lixi	Eye Clinic – Department of Surgical Sciences – University of Cagliari – Italy
Silvia	Corrias	Endocrinology Unit – Department of Medical Sciences – University of Cagliari – Italy
Laura	Pinna	Endocrinology Unit – Department of Medical Sciences – University of Cagliari – Italy
Claudia	Cord	Eye Clinic – Department of Surgical Sciences – University of Cagliari – Italy
Federica	Diana	Endocrinology Unit – Department of Medical Sciences – University of Cagliari – Italy
Ludovica	Pilloni	Endocrinology Unit – Department of Medical Sciences – University of Cagliari – Italy
Stefano	Mariotti	Endocrinology Unit – Department of Medical Sciences – University of Cagliari – Italy
Francesco	Boi	Endocrinology Unit – Department of Medical Sciences – University of Cagliari – Italy
Giuseppe	Giannaccare	Eye Clinic – Department of Surgical Sciences – University of Cagliari – Italy
Giulia	Lanzolla	Endocrinology Unit – Department of Medical Sciences – University of Cagliari – Italy

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