Can you get thyroid eye disease with normal thyroid levels?

Yes. NIDDK says the eye disease can develop even if thyroid function is normal. The American Thyroid Association and European Thyroid Association consensus statement calls this form rare and says the disease is almost always seen with TSH receptor antibodies in the blood.

Does thyroid eye disease go away on its own?

Often it improves. The National Eye Institute says symptoms usually last 1 to 2 years and often go away on their own. The 2022 consensus statement says bulging and eye muscle problems may persist in up to 50% of patients without treatment.

Is radioactive iodine safe if I already have eye symptoms?

It depends on how active and severe the eye disease is. The 2021 European guideline recommends low-dose oral prednisone with radioactive iodine in mild active eye disease, and prefers antithyroid drugs when eye disease is active and moderate-to-severe. Your endocrinologist and eye doctor make this decision with you.

Does smoking make thyroid eye disease worse?

Yes. The National Eye Institute says smoking raises the risk of eye problems in Graves' disease and makes the eye disease worse. In a 2009 Swedish randomized trial, smokers had the highest risk of new or worse eye disease with either radioactive iodine or medicine.

What Is Thyroid Eye Disease, and Can It Start After Graves' Treatment?

Q: Does Tepezza cause hearing loss?

It can. The FDA label says Tepezza may cause severe hearing impairment, including hearing loss that in some cases may be permanent. Hearing impairment occurred in 10% of patients in the premarketing trials. The label tells doctors to assess hearing before, during, and after treatment.

The short answer: Thyroid eye disease (TED) is an autoimmune condition. The immune system attacks the muscles and fat behind the eyes, and the swelling pushes the eyes forward. The National Eye Institute says about 1 in 3 people with Graves' disease get some eye problems. Yes, it can start after Graves' treatment. In randomized trials, new or worse eye disease was more common after radioactive iodine than after antithyroid medicine.

What is thyroid eye disease?

Thyroid eye disease has several names: Graves' eye disease, Graves' ophthalmopathy, and Graves' orbitopathy. They all mean the same condition. The National Eye Institute explains that the immune system attacks the muscles and other tissues around the eyes. The tissue behind the eye swells, and the eyes bulge out.

The disease is linked to the same antibodies that cause Graves' hyperthyroidism. A 2022 consensus statement from the American Thyroid Association and European Thyroid Association says TED is almost always seen together with TSH receptor antibodies in the blood. Our guide to thyroid blood tests explains those antibody tests.

Most cases are mild. The same consensus statement puts the overall rate of TED in Graves' disease at up to 40%. Moderate-to-severe disease occurs in about 6% of people with Graves' disease. Sight-threatening disease occurs in about 0.5%.

What are the symptoms of thyroid eye disease?

The main symptom is bulging eyes. The National Eye Institute lists these other symptoms:

Dry, gritty, red, or irritated eyes
Puffy eyelids
Eyelids that pull back more than usual or do not close all the way
Double vision
Sensitivity to light
Eye pain or pressure
Trouble moving the eyes

The disease usually affects both eyes, but you may notice symptoms in only one. Dry or gritty eyes have many other causes too. symptom.md covers common eye symptoms that are not from the thyroid.

TED has an active phase and an inactive phase. The consensus statement says patients usually enter the inactive phase 12 to 18 months after the disease starts. Symptoms improve in that phase. Bulging and eye muscle problems often do not return to normal without treatment, and they may persist in up to 50% of patients.

Can thyroid eye disease start after Graves' treatment?

Yes. The eye disease and the thyroid disease follow separate courses. NIDDK says eye symptoms can start before hyperthyroid symptoms or at the same time. It also says the eye disease can develop after Graves' disease is treated, and even when thyroid function is normal. NIDDK calls late onset rare.

Timing explains most cases. The consensus statement reports that in 80% of people who get both conditions, the two start within 2 years of each other. Treatment for hyperthyroidism usually happens inside that same window. So eye disease often first appears while a person is on treatment or soon after it.

A Swedish randomized trial of 168 patients shows this. Eye disease developed for the first time in 13% of patients during at least 24 months of follow-up. Eye disease developed or worsened in every treatment group: medicine, surgery, and radioactive iodine. Thyroid treatment does not cure the autoimmune process behind the eyes.

Does radioactive iodine raise the risk?

Yes. Three randomized trials point the same way.

Sweden, 1992. In patients aged 35 to 55, eye disease developed or worsened in 33% after radioactive iodine. The rate was 10% with antithyroid medicine and 16% with surgery (Tallstedt and colleagues).
Italy, 1998. Among 150 patients given radioactive iodine, eye disease developed or worsened in 15% within two to six months. The change did not last in most of them. It persisted in 5%, who then needed treatment for their eyes. With methimazole, 3% worsened (Bartalena and colleagues).
Sweden, 2009. Over 4 years, eye disease developed or worsened in 38.7% after radioactive iodine and 21.3% after medicine. Most of the difference came from new cases (Traisk and colleagues).

The rates differ because the trials used different patients, follow-up times, and definitions. The direction is the same in all three. NIDDK also warns that radioiodine therapy may worsen eye symptoms.

Radioactive iodine is still a common and effective treatment. For people with active moderate-to-severe eye disease, the 2021 European Group on Graves' Orbitopathy guideline prefers antithyroid drugs to control the thyroid.

Who is most at risk, and can you lower the risk?

The European guideline lists these risk factors: smoking, thyroid levels out of range, high TSH receptor antibody levels, radioactive iodine treatment, and high cholesterol.

Smoking is the largest risk you can change. In the 2009 Swedish trial, smokers had the highest risk of new or worse eye disease with either treatment. The National Eye Institute calls quitting the most important lifestyle change for this disease.

A steroid course can protect the eyes around radioactive iodine. In the 1998 Italian trial, 145 patients took a 3-month course of prednisone after radioactive iodine. None had progression of eye disease. The European guideline recommends low-dose oral prednisone with radioactive iodine for people with mild active eye disease, especially if they have other risk factors. Your endocrinologist decides if you need it.

Keep thyroid levels in range. Thyroid dysfunction is on the risk list. In the Italian trial, doctors promptly corrected both an underactive thyroid and persistent hyperthyroidism after treatment. Go to your follow-up blood tests after any Graves' treatment.

How is thyroid eye disease treated?

Treatment depends on how active and how severe the disease is.

Mild disease. The National Eye Institute lists artificial tears, sunglasses, a raised head of the bed for puffy eyelids, and prism glasses for double vision. Selenium has trial evidence in mild disease. In a European trial of 159 patients, six months of selenium improved quality of life and slowed progression compared with placebo. The consensus statement says a single six-month course may be considered, mainly in regions where selenium intake is low. It also says the benefit in selenium-sufficient regions is an open question. Ask your doctor before you take it. supplements.md has more on supplement safety.

Moderate-to-severe disease. The European guideline says intravenous steroids work better and are better tolerated than oral steroids. Teprotumumab (Tepezza) is an FDA-approved infusion medicine for this disease. The FDA label says it treats thyroid eye disease regardless of disease activity or duration. It is given as eight intravenous infusions, one every three weeks.

The label carries a hearing warning. Tepezza may cause severe hearing impairment, including hearing loss that in some cases may be permanent. Hearing impairment occurred in 10% of patients in the two premarketing trials and 19% in two later trials. The label tells doctors to check hearing before, during, and after treatment. Other warnings cover infusion reactions, high blood sugar, flares of inflammatory bowel disease, and harm to a fetus.

Surgery. Orbital decompression makes the eye socket bigger. Eye muscle surgery and eyelid surgery correct double vision and eyelid position. The consensus statement says this rehabilitative surgery is done when the disease is inactive and thyroid levels are stable.

When do eye symptoms need urgent care?

In rare cases, swelling presses on the optic nerve and causes vision loss. The consensus statement says sight-threatening disease needs urgent referral. Call your doctor the same day or go to emergency care for:

Loss of vision, or vision that becomes dim
Colors that look faded or washed out
An eye that will not close and is very painful

Faded color vision and loss of central vision are common findings when the optic nerve is compressed, according to the consensus statement. Do not wait for your next routine visit.

The bottom line

Thyroid eye disease is an autoimmune disease of the tissues behind the eyes. It affects about 1 in 3 people with Graves' disease, and most cases are mild. It can start before, during, or after Graves' treatment. Radioactive iodine raises the risk more than antithyroid medicine does, and smoking raises it with any treatment. If you smoke or already have eye symptoms, tell your endocrinologist before you choose a treatment. Report any change in vision at once.

Last updated: October 2026. This article is for informational purposes only and does not constitute medical advice. Talk with your endocrinologist and an eye doctor about Graves' treatment choices and any new eye symptoms.