What is the treatment for exophthalmos in Grave's disease?

Treatment of Exophthalmos in Graves' Disease

The treatment of exophthalmos in Graves' disease should begin with ocular lubricants and selenium supplementation for mild cases, progress to teprotumumab for moderate-to-severe active disease, and consider orbital decompression surgery for severe cases with proptosis or optic neuropathy that don't respond to medical therapy. 1

Initial Assessment and Management

• Ocular lubricants are essential first-line therapy to combat exposure related to eyelid retraction and proptosis 1
• Preservative-free topical lubrication is strongly recommended for patients requiring long-term eye drop administration 2
• Examples include carboxymethylcellulose 0.5-1%, carmellose sodium, hyaluronic acid, and petrolatum ointment at night for nocturnal lagophthalmos 2
• Lipid-containing eye drops are particularly effective for patients with meibomian gland dysfunction 2
• Selenium supplementation has shown efficacy in reducing inflammatory symptoms in milder thyroid eye disease through its antioxidant effect 1
• Punctal plugs can provide additional relief for severe dry eye symptoms 1

Medical Treatment Options

• Teprotumumab (IGF-IR inhibitor) is highly effective in reducing proptosis and clinical activity score in patients with active disease 1
• Mycophenolate mofetil is an immunosuppressive option for refractory cases 1

Surgical Interventions

• Orbital decompression should be considered for severe proptosis or optic neuropathy that doesn't respond to medical therapy 1
• Endoscopic orbital decompression can reduce proptosis by an average of 3.2 mm when performed alone 3
• Combined endoscopic and lateral orbital decompression can achieve an average reduction of 5.6 mm in proptosis 3
• Surgical treatment should follow a specific sequence 1:
  1. Orbital decompression (when needed)
  2. Strabismus surgery (after stable alignment for at least 6 months)
  3. Eyelid surgery

Specific Surgical Approaches

• Transpalpebral decompression by removal of intraorbital fat 4
• Three-wall osseous expansion 4
• Zygomatic osteotomy 4
• Kennedy's surgical approach has shown reduced morbidity compared to Walsh and Ogura technique, with fewer complications like diplopia and infraorbital nerve lesion 5

Management of Associated Complications

• For eyelid retraction, recession of the levator muscle with scleral graft implantation may be performed 6
• For oculomotor disturbances and diplopia, surgery typically involves recession of the involved muscles, particularly the inferior and medial rectus 6
• Fresnel or ground-in prism can provide temporary relief from diplopia while awaiting definitive treatment 1
• Botulinum toxin injection during the active phase can temporarily relieve 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 1
• Imaging (CT or MRI) can confirm diagnosis and evaluate extraocular muscle size and orbital fat volume 1

Common Pitfalls to Avoid

• Delaying treatment of severe ophthalmopathy, which can lead to permanent vision loss 1
• Performing strabismus surgery before orbital decompression, which can result in unpredictable outcomes as decompression can worsen or create new strabismus 1
• Failing to recognize that smoking increases the risk and severity of orbitopathy 2