What is the initial management for thyroid eye disease?

From the Guidelines

The initial management of thyroid eye disease should focus on supportive measures, including cessation of smoking, use of artificial tears, and selenium supplementation, as well as medical therapy with teprotumumab for moderate-to-severe active disease, as it has been shown to reduce proptosis and clinical activity score of disease in many patients with active TED 1.

Key Components of Initial Management

• Patients should be advised to stop smoking immediately as it worsens disease progression and reduces treatment effectiveness
• Artificial tears (preservative-free) should be used frequently during the day, with lubricating ointments at night for dry eye symptoms
• Sleeping with the head elevated can reduce periorbital edema
• For mild inflammation, cool compresses and over-the-counter NSAIDs may provide relief
• Selenium supplementation at 100 mcg twice daily is recommended for mild disease, as it can slow progression
• Prismatic glasses may help with diplopia

Medical Therapy

• For moderate-to-severe active disease, oral glucocorticoids are typically used, often starting with prednisone 40-60 mg daily for 4-6 weeks followed by a slow taper over 2-3 months
• For severe, sight-threatening disease, high-dose IV methylprednisolone (500-1000 mg daily for 3 consecutive days) may be necessary
• Teprotumumab, an insulin-like growth factor-1 receptor inhibitor, is now available for moderate-to-severe disease, administered as IV infusions every 3 weeks for a total of 8 doses, and has been shown to improve subjective diplopia scores in both active and chronic TED and reduce the need for strabismus surgery 1

Considerations for Surgical Interventions

• Orbital decompression, high-dose pulse steroid infusion, and, in some cases, orbital radiation treatment are often indicated for severe proptosis or compressive optic neuropathy
• 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
• 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 1

From the Research

Initial Management for Thyroid Eye Disease

The initial management for thyroid eye disease can vary depending on the severity and activity of the disease.

• For mild disease, observation or symptomatic treatments may be sufficient 2.
• Non-surgical management options include oral selenium, glucocorticoid therapy, cyclosporin, mycophenolate, rituximab, immunoglobulin, teprotumumab, and orbital radiotherapy 2, 3.
• High-dose intravenous methylprednisolone therapy is used in active vision-threatening disease, often in combination with other treatments such as tarsorrhaphy and orbital decompression 2, 4.

Treatment Selection

Treatment selection is guided by the severity of the disease, graded by the NOSPECS system, and the activity of the disease, assessed by the clinical activity score (CAS) 2.

• Systematic assessment and management by both an endocrinologist and ophthalmologist is crucial to achieve and maintain euthyroidism and select the most appropriate treatments 2.
• The use of steroid therapy, particularly intravenous corticosteroids, has been shown to be effective in reducing inflammation and improving outcomes in moderate to severe thyroid eye disease 5.

Surgical Intervention

Surgical intervention may be required in vision-threatening conditions or to counteract the sequelae of the inflammatory phase 4, 3.

• Orbital decompression, strabismus surgery, and eyelid retraction repair are common surgical procedures used to manage thyroid eye disease 4, 3.
• Advances in surgical techniques, such as stereotactic image-guided balanced orbital decompression with an endoscopic approach, have improved outcomes and minimized trauma 3.