Purpose Research on strabismus surgery for Thyroid Eye Disease (TED) is limited, with insufficient data on surgical dose–response. This study aimed to assess outcomes and dose–response in initial strabismus surgeries using a large TED sample. Methods A retrospective review of TED patients undergoing initial strabismus surgery (2013–2023) at Zhongshan Ophthalmic Center included data on demographics, ocular deviation, motility, surgical techniques, and outcomes. Surgeries involved rectus recession and tenotomy, with traction sutures (TS) applied for deviations > 35 prism diopters (PD). Success was defined as no diplopia and deviation ≤ 10 PD horizontally, ≤ 5 PD vertically. Dose–response (deviation change per mm rectus recession, DPR) and influencing factors were analyzed. Results Among 104 patients, rectus recession had a 70.65% success rate, while tenotomy achieved 12.5%. Success was highest for superior rectus (SR) recession (88.00%), followed by inferior rectus (IR) (70.00%) and medial rectus (MR) (38.46%). Two-muscle recessions succeeded in 55.56%. In single rectus recession with TS, DPR for IR, SR, and MR was 6.96 ± 2.18, 5.92 ± 1.14, and 9.78 ± 5.80 PD/mm, respectively, versus 4.26 ± 0.78, 3.95 ± 0.83, and 3.86 ± 0.29 PD/mm without TS. Preoperative deviation significantly affected DPR, especially in IR/SR surgeries (P < 0.001). Simultaneous MR recession did not alter IR/SR DPR in TS (P = 0.266) or non-TS (P = 0.138) groups. However, in non-TS cases, IR/SR recession impacted MR DPR (P = 0.034), but this effect was absent with TS (P = 0.741). Conclusions Single rectus recession achieves high success for TED vertical strabismus, with TS enhancing correction. Preoperative deviation is key to dose–response, while vertical recession influences horizontal dose–response when deviation is < 35PD.

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