Smoking can increase the likelihood that a patient with thyroid eye disease (TED) will require surgery, a study published in the American Journal of Ophthalmology shows. This risk is decreasing among former smokers, according to the study.

Researchers looked at the US database, Intelligent Research in Sight (IRIS®) Registry, from years 2013 to 2020, to gather de-identified records of individuals 18 years of age or older who visited a clinic for TED. This study assessed 5-year cumulative probability for 3 TED-related procedures: eyelid recession, orbital decompression, and strabismus surgery. After exclusions for prior operations or lack of smoking status, 87,774 remained, median age 59 (IQR 48–68) years, and 81% female. The cohort comprised 57% who never smoked, 24% former smokers, and 19% current smokers.

A greater number of patients who smoke, 4.1%, underwent eyelid recession surgery, compared with 2.6% for patients who have quit smoking or 2.6% for those who never smoked. After statistical adjustment for sex, age, ethnicity, race, and region of residence; those who smoke are much more likely than those who do not to undergo the procedure, with a hazard ratio (HR) of 1.7 (95% CI 1.5–1.9, P <.001). Those who have ceased smoking were somewhat more likely than those who never smoked (HR, 1.2; 95% CI 1.0–1.4).

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Regarding orbital decompression, patients who smoke also showed a higher probability to have the surgery, 3.7%, as opposed to 2.1% for those who have quit, and 1.9% for those who never smoked. Upon statistical correction for demographic factors, those who smoke experienced an HR of 2.1 (95% CI 1.8–2.4, P <.001), although those who quit smoking displayed a smaller HR at 1.27 (95% CI 1.09–1.47).

Likewise, 4.6% of patients who smoke received strabismus surgery vs 3.1% of patients who quit smoking, and 2.2% in those who never smoked. Adjusted data revealed higher risk for patients who currently smoke at HR of 2.0 (95% CI 1.8–2.3, P <.001) compared with tho who never smoked, and  patients who have quit smoking (HR, 1.3; 95% CI 1.1–1.5). 

“Physicians should be aware of the long-term burden of surgical disease associated with smoking in TED and counsel active smokers with Graves disease on the benefits of smoking cessation,” according to the researchers.

Women tended less than males to have orbital decompression or strabismus surgery, although not eyelid recession. Patients who are Black also had less strabismus procedures than indviduals who are nonHispanic White. With older age, fewer participants had eyelid recession and orbital decompression, but younger individuals tended less to experience strabismus surgery.

While complete etiology of TED is still unknown, prior research suggests orbital fibroblasts express antigens that interact with passing antibodies, prompting changes in connective tissue and more edema in the periorbital area. Smoking contributes reactive oxygen species to already oxidatively stressed tissue, with additional orbital fibroblasts being generated. 

Limitations of this analysis involve self-reporting of tobacco use, possibly causing underestimation; some cases of TED may resolve spontaneously, biasing the cohort to more advanced disorder; and patients could have sought surgery at practices not participating in IRIS. Also, a medication introduced in the US in 2020 adds another option for TED treatment — teprotumumab.

Disclosure: Multiple study authors declared affiliations with the biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Oke I, Reshef ER, Elze T, et al., on behalf of the IRIS R Registry Analytic Center Consortium. Smoking is associated with a higher risk of surgical intervention for thyroid eye disease in the IRIS® Registry, Am J Ophthalmol. January 19, 2023. doi:10.1016/j.ajo.2023.01.020

This article originally appeared on Ophthalmology Advisor