What is the treatment for Graves' eye disease?

Treatment for Graves' Eye Disease

The treatment for Graves' eye disease should follow a stepwise approach, starting with ocular lubricants for mild cases and progressing to more aggressive interventions like teprotumumab or surgery for severe cases, based on disease activity and severity. 1

Initial Assessment and Management

• All patients with Graves' eye disease require thorough assessment of disease activity and severity to guide appropriate treatment selection 1
• Preservative-free topical lubrication is essential first-line therapy for all patients with Graves' ophthalmopathy to combat exposure related to eyelid retraction and proptosis 1
• Lipid-containing eye drops are particularly beneficial for patients with concurrent meibomian gland dysfunction 1
• Punctal plugs should be considered for patients with severe dry eye symptoms that don't respond adequately to lubricants alone 1
• Selenium supplementation (200 μg daily) is recommended for patients with mild disease due to its antioxidant effects that reduce inflammatory symptoms 1

Medical Treatment Options Based on Disease Severity

Mild Disease

• Conservative management with artificial tears, cool compresses, sleeping with elevated head, and eyelid taping at night is effective for mild cases 2
• Risk factor modification, particularly smoking cessation, is crucial as smoking increases both risk and severity of orbitopathy 1
• Normalization of thyroid function is essential for all patients with Graves' ophthalmopathy 3

Moderate-to-Severe Active Disease

• Intravenous glucocorticoid therapy is the standard first-line treatment for moderate-to-severe active Graves' ophthalmopathy 3
• Teprotumumab, an IGF-IR inhibitor, has shown impressive efficacy in reducing proptosis and clinical activity scores in patients with active disease and should be considered early in treatment 1, 3
• If there's inadequate response to glucocorticoids, second-line options include:
  • Orbital radiotherapy (with additional glucocorticoids) 3
  • Rituximab for refractory cases 3
  • Mycophenolate mofetil as an immunosuppressive option 1, 3
  • Cyclosporine or methotrexate in select cases 3

Surgical Interventions

• Surgical intervention should be considered for patients with:

  • Severe proptosis not responding to medical therapy 1
  • Compressive optic neuropathy unresponsive to medical treatment 1
  • Significant strabismus causing diplopia 4
  • Eyelid retraction causing exposure keratopathy 5

• The surgical sequence should strictly follow this order to avoid complications:

  1. Orbital decompression (when needed) 1
  2. Strabismus surgery (after stable alignment for at least 6 months) 1, 4
  3. Eyelid surgery 1

• Transpalpebral decompression by removal of intraorbital fat, three-wall osseous expansion, and zygomatic osteotomy are effective surgical techniques for orbital decompression 5

Management of Diplopia

• Fresnel or ground-in prism can provide temporary relief from diplopia while awaiting definitive treatment 1
• Botulinum toxin injection during the active phase can provide temporary relief of diplopia 1
• Strabismus surgery should only be performed after orbital decompression and when eye alignment has been stable for at least 6 months 1, 4

Monitoring and Follow-up

• Regular monitoring for optic neuropathy is essential with assessment of:
  • Visual acuity 6
  • Color vision 6
  • Visual fields 6
  • Pupillary exam 6
  • Fundus examination 6
• Careful monitoring for exposure keratopathy is necessary in patients with exophthalmos 6
• 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 results in unpredictable outcomes 1, 4
• Failing to recognize that smoking significantly increases the risk and severity of orbitopathy 1
• Neglecting to address thyroid dysfunction, which can exacerbate eye symptoms 3