Treatment of Thyroid Eye Disease

Opinion statement

Thyroid eye disease (TED) is an autoimmune disease characterized by varying degrees of proptosis, congestion and inflammation of the extraocular tissues, and eyelid retraction. It is usually seen in the setting of Graves’ disease, but the severity of TED does not necessarily correlate with the level of systemic disease in a given patient. It is very important, nonetheless, to try to achieve a euthyroid state to minimize the chances of exacerbation of TED. Treatment of TED is based on the signs and symptoms displayed by the patient; there is no “one size fits all” approach. Generally, it is advisable to start with conservative measures, such as ocular lubrication with artificial tears, to manage symptoms of chronic irritation and redness. It is also imperative that the patient be advised to quit smoking, because there is a clear link between smoking and disease activity. Medical treatment with systemic oral or pulsed intravenous corticosteroids should be reserved for patients with active inflammation resulting in increased orbital pressure, compressive optic neuropathy, severe periorbital edema, or similar presentations. Once there is significant improvement in the acute inflammation, it is useful to treat patients who have residual inflammation with external beam radiation in order to be able to wean the patient off steroids and avoid their well-known complications.

If there is significant corneal exposure due to lid retraction, and the lid position has been stable for at least 6 months, eyelid surgery can be considered. If exposure is minimal, this may consist of a lateral tarsorrhaphy. For larger amounts of exposure, recession of the levator muscle, Müller’s muscle, or both can be performed. Those patients who have stable diplopia for at least 6 months are candidates for strabismus surgery. Patients who progress to severe proptosis or compressive optic neuropathy may need orbital decompression surgery. Generally, if more than one type of surgical procedure is necessary, orbital decompression is performed first, followed by strabismus surgery; eyelid surgery is performed last.