Overview - Exophthalmos (bulging eyes)

Exophthalmos, also known as proptosis, is the medical term for bulging or protruding eyeballs. It can affect 1 or both eyes and is most often caused by thyroid eye disease.

If you have exophthalmos, there is a small risk of your optic nerve (which sends signals between your eye and brain) becoming compressed, which may affect your sight permanently if it is not treated quickly.

Many of the symptoms of thyroid eye disease tend to improve over time, although this can take several years. There's a chance your eyes will continue to protrude if corrective surgery is not done.

Some people with exophthalmos are left with long-term vision problems, such as double vision. However, permanent loss of vision is rare if the condition is diagnosed and treated quickly.

When to get medical advice

See a GP or an optician if you notice that 1 or both of your eyes are protruding.

It's important to identify the cause, as treatment is often more effective if it's started as soon as possible.

If necessary, a GP or optician can refer you to an eye specialist (ophthalmologist) for further assessment.

Diagnosing exophthalmos

If you're referred to an eye specialist (ophthalmologist), they may:

check how well you're able to move your eyes
use an instrument called an exophthalmometer to measure how far your eyeball protrudes
arrange for a CT scan or MRI scan
arrange for a blood test to check how well your thyroid gland is working

You may be referred to a doctor who specialise in conditions affecting glands and hormones (endocrinologist) if your thyroid hormone levels are found to be abnormal.

Causes of exophthalmos

One of the main causes of exophthalmos in the UK is thyroid eye disease, also known as Graves' ophthalmopathy disease.

Graves' ophthalmopathy disease affects around 1 in every 3 people with an overactive thyroid gland (hyperthyroidism) caused by Graves' disease. It's more common in women and people who smoke.

Graves' disease is an autoimmune condition, which is where the immune system mistakenly attacks healthy tissue.

In the case of thyroid eye disease, the immune system attacks the muscles and fatty tissues around and behind the eye, making them swollen.

Thyroid eye disease can also occasionally affect people with an underactive thyroid gland (hypothyroidism) and, in rare cases, people with normal thyroid function.

Other causes

Exophthalmos can also have other causes, but these are generally less common.

Other causes of exophthalmos can include:

an injury to the eyes
bleeding behind the eyes
abnormally shaped blood vessels behind the eyes
an infection of the tissue in the eye socket
cancerous tumours, such as those caused by neuroblastoma and some soft tissue sarcomas

Rarely, exophthalmos can also affect newborn babies.

Treating exophthalmos

If exophthalmos is caused by thyroid eye disease, the following treatments are often helpful:

medicine to correct the level of thyroid hormones in your blood. This will not necessarily improve the problems with your eyes, but may stop them getting worse
steroid injections into a vein (intravenously) – this can help reduce the inflammation associated with the condition
corrective surgery – this may be done to improve the appearance of your eyes once the inflammation is under control

Other useful treatments include using eye drops to reduce eye dryness and irritation, and wearing special lenses to correct double vision. Stopping smoking can also help.

In other cases, treatment will vary depending on the cause. For example, radiotherapy, chemotherapy and/or surgery may be recommended if exophthalmos is caused by a tumour.

Find out more about treating exophthalmos.

Complications of exophthalmos

Depending on what's causing your bulging eyes, you may also have other associated symptoms. For example, if exophthalmos is caused by a thyroid eye disease, your eyes may also be:

inflamed, red and painful
dry and "gritty"
tearful
sensitive to light (photophobia)

You may also experience some double vision.

If you have severe exophthalmos, you may not be able to close your eyes properly. This can damage the transparent tissue that covers the front of your eyes (corneas) by causing them to dry out.

If your corneas become very dry, an infection or ulcers may develop. These could damage your vision if left untreated.

Page last reviewed: 29 October 2019
Next review due: 29 October 2022

Treatment - Exophthalmos (bulging eyes)

Treatment for bulging eyes (exophthalmos) depends on what is causing the problem.

An eye specialist (ophthalmologist) may sometimes advise you that immediate treatment is not necessary. They may recommend regular examinations to monitor your condition.

Treating thyroid eye disease

If you have thyroid eye disease, your treatment may be in several stages. This is because the condition tends to progress through 2 main phases:

an "active" phase, when dryness and redness are prominent and you may be at risk of vision problems
an "inactive" phase, when the condition has settled down, but you may be left with some long-term problems (including protruding eyes)

The active phase can last for several months to 2 years.

Correcting thyroid hormone levels

If you have an overactive thyroid gland (hyperthyroidism) or an underactive thyroid gland (hypothyroidism), you'll usually be offered medicine to correct the level of thyroid hormones in your blood.

For example, an overactive thryoid can be treated with medicines such as thionamides, which prevent your thyroid gland producing excess thyroid hormones.

Treating your thyroid problems will not necessarily improve your related eye symptoms, but it may help prevent other problems associated with abnormal thyroid levels. It may also prevent bulging eyes from getting worse.

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Self-care

You may also be advised about treatments and things you can do yourself to relieve some of the symptoms associated with the active phase of thyroid eye disease.

These include:

stopping smoking if you smoke, as smoking can significantly increase the risk of eye problems getting worse
using extra pillows in bed at night to help reduce some of the puffiness around your eyes
wearing sunglasses if you have sensitivity to light (photophobia)
trying to avoid exposing your eyes to irritants such as dust
using eye drops to help relieve soreness and moisten your eyes if you have dry eyes
wearing glasses containing special prisms designed to help correct double vision

If thyroid eye disease is mild, self-care and medicines to correct your thyroid hormone levels may be all the treatment you need.

Steroids

In some cases, when the eyes are very painful and inflamed during the active phase of thyroid eye disease, steroids may be recommended.

Steroids are powerful medicines that can help control inflammation. They can help to make the condition stable before any type of surgery is considered.

In many cases, steroid injections, given directly into a vein (intravenously), are recommended. This is because taking steroid tablets over a long period of time can have significant side effects.

Treatment with steroid injections usually involves weekly injections over 10 to 12 weeks. You should start to notice an improvement in your condition after 1 to 2 weeks.

Severe side effects of steroids are uncommon, but you may experience some short-term problems for a few days following treatment, such as:

feeling agitated
having difficulty sleeping
headaches
blushing of the neck and face

Radiotherapy

Occasionally, radiotherapy may be considered during the active stage of thyroid eye disease if steroids have not been effective. It may also be combined with steroids.

Radiotherapy uses high-energy radiation to destroy cells. Low doses of radiation can be used on the eye socket to help reduce swelling.

During treatment, you'll lie down and a shell will be placed over your head to keep it still. A machine is used to carefully direct beams of radiation at the area being treated.

This is usually done as an outpatient over several days, which means you will not need to stay in hospital overnight.

Radiotherapy can cause some side effects, although these should be minimal as the treatment will be confined to a specific area and should not affect other parts of your body. However, possible side effects may include:

short-term worsening of your eye symptoms
cataracts
in rare cases, damage to the layer of tissue at the back of your eye (sight-threatening retinopathy)

Surgery

In some cases, surgery may be considered as a treatment for exophthalmos if you have severe or persistent symptoms.

For example, surgery might be used to improve the appearance of your eyes if exophthalmos has been in the inactive phase for a few months. However, medical treatment alone will not necessarily reverse the protrusion of the eyes.

Surgery may also be done during the active phase of thyroid eye disease if there's an immediate threat to your vision.

Surgery may also be effective if exophthalmos is caused by other problems, such as issues with the blood vessels behind your eyes.

Types of surgery

There are 3 main types of surgery that may be done on people with exophthalmos, although it's unusual for someone to have all 3. These include:

orbital decompression surgery, where a small amount of bone is removed from 1 or both of your eye sockets
eyelid surgery to improve the position, closure or appearance of your eyelids
eye muscle surgery to bring your eyes into alignment and reduce double vision

These operations are usually done under general anaesthetic, which means you'll be asleep. Depending on the type and extent of the operation you have, you may need to stay in hospital for a few days afterwards.

Orbital decompression surgery

Orbital decompression surgery is most often done to improve the appearance of the eyes in people with thyroid eye disease who are affected by exophthalmos. It may also be required to reduce pressure on the optic nerve.

During the operation, a small amount of bone is removed from your eye sockets (orbits) and some of the fat surrounding the socket may also be removed.

This allows any excess tissue that's pushing the eyeballs forward to move down into the space below. It also allows your eyes to sit further back in your head, so they do not protrude forward as much.

This operation is done under general anaesthetic and usually involves making cuts (incisions) near to where your eyelids meet in the inner corner of your eyes (the point nearest the nose). You may need to stay in hospital for 1 to 2 days afterwards so your recovery can be closely monitored.

Possible complications that can happen after orbital decompression surgery include:

persistent double vision
a build-up of blood in the eye socket (haematoma)
infection where the incision was made

If you're considering having orbital decompression surgery, ask your doctor or surgeon to explain the benefits and risks of the procedure to you.

Treating other causes of exophthalmos

For most other problems that cause exophthalmos, treatment will vary, depending on the underlying cause.

For example, if you have an infection affecting the tissue in your eye socket, such as cellulitis, an eye specialist may prescribe antibiotics to treat the infection. They may also need to drain any abscesses that have developed.

If you have a tumour behind your eye, your doctor will discuss treatment options with you. For most types of cancer, treatment involves one or more of the following:

chemotherapy – where medicine is used to kill the cancerous cells
radiotherapy – where radiation is used to kill the cancerous cells
surgery to remove the cancerous tumour

Driving

If you have thyroid eye disease, your ability to drive may be affected.

You're legally obliged to inform the Driver and Vehicle Licensing Agency (DVLA) about a medical condition that could have an impact on your driving ability.

GOV.UK provides information and advice on how to tell the DVLA that you've stopped driving or need to stop.