From the Guidelines
Graves' ophthalmopathy, also known as Graves' orbitopathy, is an autoimmune condition affecting the eyes, typically associated with Graves' disease, causing inflammation and swelling of the tissues around the eyes, leading to symptoms like eye bulging, double vision, and eye irritation. According to the most recent study 1, management of Graves' ophthalmopathy involves a multi-faceted approach, including:
- Ocular lubricants to combat exposure related to eyelid retraction and proptosis
- Punctal plugs can be useful
- Patients should be counseled to cease smoking
- Selenium supplementation in patients with selenium deficiency has been shown to reduce some inflammatory symptoms in patients with milder TED
- Teprotumumab, a human monoclonal antibody inhibitor of IGF-IR, reduces proptosis and the clinical activity score of disease in many patients with active TED Some key points to consider in management:
- Teprotumumab treatment has been shown to improve subjective diplopia scores in both active and chronic TED and reduce the need for strabismus surgery 1
- Orbital decompression, high-dose pulse steroid infusion, and, in some cases, orbital radiation treatment are often indicated for severe cases
- Consultation with an orbital disease specialist should be considered in patients with concurrent proptosis and significant strabismus, even in the absence of compressive optic neuropathy 1
- Surgery on the eyelids is typically delayed until after strabismus repair
- Patients can be observed if there is no diplopia in primary gaze or reading position, and if the angle of strabismus is not stable for at least 4 to 6 months and if there are still signs of active disease 1
From the Research
Definition and Prevalence of Graves' Ophthalmopathy
- Graves' ophthalmopathy (GO) occurs in 25-50% of cases of Graves' disease 2
- Most cases are mild, with only 5% representing eye-threatening diseases 2
- About 5-10% of cases can be euthyroid and 10% hypothyroid, respectively 2
Symptoms and Characteristics
- Patients with Graves' orbitopathy suffer from disfiguring proptosis, orbital pain, and diplopia 3
- Compression of the optic nerve may cause functional restrictions to the point of loss of vision 3
- Symptoms include photophobia, sandy feeling in the eye, painful eye movements, and diplopia 4
- Visual acuity may be reduced 4
Treatment and Management
- Essential conditions for successful treatment include well-controlled thyroid dysfunction, smoking cessation, and referral to specialized thyroid eye centers as soon as possible 2
- Local therapy to maintain wet eye (lubricants) and supplementation of selenium deficiency is adequate in mild cases of GO 2
- Intravenous glucocorticoids are the first-line treatment for moderate to severe and sight-threatening GO 2, 3
- A combination with mycophenolate or radiotherapy could be considered in cases of moderate to severe and sight-threatening GO 2
- Surgical orbital decompression or tarsorrhaphy may be warranted in rare cases of sight-threatening GO 2