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Anne Strong Caldwell,1 Jennifer L Patnaik,1 Melisa Ackerman,1 Karen L Christopher,1 Anne M Lynch,1 Jasleen K Singh2 1Department of Ophthalmology, University of Colorado School of Medicine, Aurora, CO, USA; 2Department of Ophthalmology, Children’s Hospital of Colorado, Aurora, CO, USACorrespondence: Jasleen K SinghDepartment of Ophthalmology, Children’s Hospital of Colorado, 13123 E 16th Ave, Mailstop B430, Aurora, CO, 80045, USATel +1 706-877-0869Email Jasleen.singh@cuanschutz.eduPurpose: To investigate the risk of unexpected refractive prediction error after cataract surgery in patients with thyroid eye disease (TED) at the University of Colorado.Patients and Methods: A retrospective observational study was performed using records of patients who underwent cataract surgery (2014 to 2018) who were included in a Cataract Surgery Outcomes database. Any patient with documentation of thyroid eye disease (TED) in the medical record was classified as TED. Post-operative refraction error greater than or equal to ± 1.0 diopter from the target refraction was the main outcome of this study. Eyes with history of refractive surgery, ocular trauma, retinal detachment, non-Graves’ disease thyroid conditions or Graves’ disease without TED, and eyes without refractive error at follow-up were excluded.Results: A total of 5716 eyes from 3692 patients who underwent cataract surgery were analyzed. Sixty-five eyes of thirty-nine patients (1.1%) had TED. Former and/or current cigarette use was associated with having TED (p = 0.0504). Patients with TED had a statistically significant shorter axial length as compared to eyes without TED (p = 0.0257). Three hundred and forty-nine eyes (6.1%), including 9 eyes (13.8%) in patients with TED, had refractive prediction error greater than ± 1.0 diopter following surgery (univariate OR = 2.5, 95% CI: 1.1– 5.7, p = 0.0274). After multivariate analysis controlling for race, tobacco use, combined surgery, and axial length, TED was associated with an increased risk of our primary outcome, refractive prediction error greater than ± 1.0 diopter (OR = 2.4, 95% CI: 1.0– 5.7, p = 0.0506).Conclusion: Patients with TED are at increased risk for refractive prediction error following cataract surgery. Discussion with patients regarding their risk and possible need for glasses following surgery is important for setting realistic patient expectations.Keywords: thyroid eye disease, cataract surgery, refractive surprise, graves disease