What is the treatment for Graves' ophthalmopathy?

Treatment for Graves' Ophthalmopathy

The first-line treatment for Graves' ophthalmopathy includes ocular lubricants to combat exposure related to eyelid retraction and proptosis, along with selenium supplementation for milder cases, while teprotumumab (IGF-IR inhibitor) is the most effective intervention for active moderate to severe disease. 1, 2

Initial Assessment and Management

• Ocular lubricants are almost always needed to combat exposure related to eyelid retraction and proptosis in patients with Graves' ophthalmopathy 1
• Punctal plugs can provide additional relief for severe dry eye symptoms 1
• Patients should be strongly counseled to cease smoking, as it worsens disease progression and reduces treatment effectiveness 3
• Selenium supplementation has been shown to reduce inflammatory symptoms in patients with milder thyroid eye disease, particularly through its antioxidant effect 1, 2

Medical Treatment Options

• Teprotumumab, a human monoclonal antibody inhibitor of IGF-IR, is highly effective in reducing proptosis and clinical activity score in patients with active disease 1, 2, 4
• Intravenous pulse corticosteroids are significantly more effective than oral corticosteroids for moderate to severe disease, with fewer adverse events 5
• Combination of orbital radiotherapy and corticosteroids is significantly more effective than either treatment alone for moderate to severe cases 5
• Other immunosuppressive options for refractory cases include:
  • Rituximab 4
  • Tocilizumab 4
  • Mycophenolate mofetil 1

Surgical Interventions

• Orbital decompression should be considered for severe proptosis or optic neuropathy that doesn't respond to medical therapy 1, 6
• If both proptosis and significant strabismus are present, orbital decompression should be performed before strabismus surgery, as decompression can worsen or create new strabismus 1
• The surgical sequence should follow this order:
  1. Orbital decompression (when needed)
  2. Strabismus surgery (after stable alignment for at least 6 months)
  3. Eyelid surgery 1, 6

Special Considerations

• Patients with concurrent proptosis and strabismus may require consultation with an orbital specialist to consider orbital decompression prior to strabismus surgery 1
• Strabismus surgery should be delayed until after orbital decompression, as new onset or exacerbated strabismus may result from decompression 1
• Fresnel or ground-in prism can provide temporary relief from diplopia while awaiting definitive treatment 1
• Chemodenervation (botulinum toxin) during the active phase can provide temporary relief of diplopia 1

Monitoring and Follow-up

• Regular monitoring for optic neuropathy with visual acuity, color vision, visual fields, pupillary exam, and fundus exam is essential 2
• Imaging (CT or MRI) can confirm diagnosis and evaluate extraocular muscle size and orbital fat volume 1
• Multidisciplinary collaboration between endocrinologists, ophthalmologists, and orbital specialists is crucial for optimal management 7

Common Pitfalls to Avoid

• Delaying treatment of severe ophthalmopathy, which can lead to permanent vision loss 2
• Performing strabismus surgery before orbital decompression, which can result in unpredictable outcomes 1
• Failing to counsel patients about smoking cessation, which significantly worsens outcomes 3
• Underestimating the psychological impact of the disease, as quality of life improvements should be considered alongside clinical outcomes 4