From the Guidelines
Graves' eye symptoms are best managed with a multi-faceted approach, including the use of teprotumumab, a human monoclonal antibody inhibitor of IGF-IR, which has been shown to reduce proptosis and the clinical activity score of disease in many with active disease 1.
Management Approach
The management of Graves' eye symptoms involves a combination of medical and surgical treatments, depending on the severity of the symptoms.
- For mild symptoms, ocular lubricants, such as artificial tears, are almost always needed to combat exposure related to eyelid retraction and proptosis 1.
- Patients should be counseled to cease smoking, as it worsens eye symptoms and reduces treatment effectiveness 1.
- Selenium supplementation in patients with selenium deficiency has been shown to reduce some inflammatory symptoms in patients with milder TED 1.
Treatment Options
- Teprotumumab has demonstrated significant effectiveness in reducing proptosis and double vision, and is a valuable treatment option for patients with active disease 1.
- Orbital decompression, high-dose steroids, or radiation treatment should be considered for severe proptosis or optic neuropathy 1.
- Strabismus surgery is typically performed after the disease has been inactive for 6 months, and can help restore ocular alignment and reduce diplopia 1.
Importance of Controlling Underlying Thyroid Dysfunction
Throughout treatment, controlling the underlying thyroid dysfunction with antithyroid medications, radioactive iodine, or surgery is essential for long-term management 2.
- A detailed medical and ocular history should include specific questions about weight gain or loss, tachycardia, and unexplained fatigue potentially secondary to hyperthyroidism or hypothyroidism 2.
- The goal of treatment is to recognize and prevent primary vision loss, restore ocular alignment, reduce diplopia, and improve compensatory head position 2.
From the Research
Management of Graves' Eye Symptoms
The management of Graves' eye symptoms, also known as Graves' orbitopathy, involves a multi-specialty team approach, including an endocrinologist and ophthalmologist 3. The treatment options for Graves' orbitopathy depend on the severity and activity of the disease.
Treatment Options
- Local therapies and selenium are generally beneficial for patients with active, mild disease 3
- Patients with moderate-to-severe disease usually require the addition of intravenous glucocorticoid therapy 3
- Second-line therapies, such as orbital radiotherapy, rituximab, cyclosporine, mycophenolate mofetil, and methotrexate, may be considered if there is an inadequate response to glucocorticoid therapy 3
- New biologic agents, such as teprotumumab and tocilizumab, have shown promising results in reducing disease activity and severity 3, 4, 5
Lifestyle Modifications
Lifestyle modifications, including dietary changes, oral health interventions, practice of yoga, avoidance of environmental toxicants, and supportive supplements, may also be beneficial in managing Graves' disease and its symptoms, including Graves' orbitopathy 6
Emerging Treatments
Emerging treatments, such as immunotherapy-based approaches and new biologic agents, are being tested and may offer new options for the management of Graves' orbitopathy 4, 5