From the Guidelines
For Graves' disease with exophthalmos not responding to antithyroid drugs after 10 months, definitive treatment with near-total thyroidectomy is recommended. This approach is supported by the need to address both the hyperthyroidism and the exophthalmos effectively. Near-total thyroidectomy provides rapid and permanent control of hyperthyroidism, which is crucial for managing exophthalmos and preventing further complications 1.
Management Considerations
- The use of antithyroid drugs for more than 10 months without response indicates a low likelihood of achieving euthyroidism with continued medical management alone 1.
- Near-total thyroidectomy is preferred over subtotal thyroidectomy because it reduces the risk of recurrent hyperthyroidism and allows for better control of thyroid eye disease 1.
- Radioiodine therapy is an alternative, but it may not be as effective in rapidly controlling hyperthyroidism and exophthalmos as near-total thyroidectomy 1.
- Additional management for exophthalmos includes selenium supplementation, lubricating eye drops, elevation of the head while sleeping, and smoking cessation 1.
- In severe cases of thyroid eye disease, intravenous methylprednisolone or teprotumumab may be necessary 1.
Multidisciplinary Approach
A multidisciplinary approach, combining the expertise of medical specialists in endocrinology, oculoplastics, and neuro-ophthalmology, is recommended for the treatment of TED 1. This approach ensures comprehensive management of both the thyroid disease and the exophthalmos, leading to better outcomes in terms of morbidity, mortality, and quality of life.
Quality of Life and Outcomes
The primary goal of managing Graves' disease with exophthalmos is to improve the patient's quality of life by controlling hyperthyroidism, reducing the symptoms and complications of exophthalmos, and minimizing the risk of long-term morbidity and mortality 1. Near-total thyroidectomy, as part of a multidisciplinary treatment plan, offers the best chance of achieving these outcomes for patients who have not responded to antithyroid drugs after 10 months.
From the Research
Management of Graves' Disease with Exophthalmos
The management of Graves' disease with exophthalmos that is not responding to antithyroid drugs for 10 months can be considered with the following options:
- Surgical Intervention: Near-total thyroidectomy is a viable option for patients with Graves' disease who have large goiters, moderate to severe ophthalmopathy, or are noncompliant with antithyroid drugs 2, 3, 4.
- Radioiodine Therapy: Although radioiodine therapy is a common treatment for Graves' disease, it may not be the best option for patients with exophthalmos, as it can worsen ophthalmopathy in some cases 3.
- Continuation of Antithyroid Medication: Continuing antithyroid medication for 12-18 months may lead to remission in some patients, but the likelihood of remission decreases with longer treatment duration 3.
Considerations for Exophthalmos
Exophthalmos is a significant consideration in the management of Graves' disease. Studies have shown that:
- Surgery can improve exophthalmos: Total thyroidectomy can lead to regression of ophthalmopathic exophthalmos in patients with Graves' disease 5.
- Radioiodine therapy may worsen exophthalmos: Radioiodine therapy can worsen ophthalmopathy in some patients, making it a less desirable option for those with exophthalmos 3.
Treatment Options
Based on the evidence, the treatment options for Graves' disease with exophthalmos that is not responding to antithyroid drugs for 10 months are:
- Near-total thyroidectomy: A surgical option that can improve exophthalmos and provide definitive treatment for Graves' disease 2, 3, 5, 4.
- Radioiodine therapy: A non-surgical option that can provide definitive treatment for Graves' disease, but may not be the best option for patients with exophthalmos 2, 3.