How should mild Graves disease–related exophthalmos (minimal proptosis, no diplopia, no optic nerve compression, mild soft‑tissue swelling) be managed?

Management of Mild Graves Disease-Related Exophthalmos

For mild exophthalmos without diplopia, optic nerve compression, or severe soft tissue involvement, conservative management with ocular surface protection, smoking cessation, and observation is the appropriate initial approach. 1, 2

Conservative Management Strategy

Ocular Surface Protection

• Apply ocular lubricants (artificial tears and ointments) to prevent exposure keratopathy from eyelid retraction and mild proptosis. 1, 2
• Consider punctal plugs to enhance tear retention and reduce corneal exposure risk. 1
• Use broad-spectrum topical antibiotics (quinolone preparations like moxifloxacin or levofloxacin four times daily) if fluorescein staining reveals epithelial defects. 3

Risk Factor Modification

• Counsel patients to cease smoking immediately, as smoking significantly increases both risk and severity of thyroid eye disease. 1, 4
• Smoking is one of the most modifiable risk factors with substantial impact on disease progression. 4

Selenium Supplementation

• Consider selenium supplementation in patients with documented selenium deficiency, as it reduces inflammatory symptoms in milder thyroid eye disease through antioxidant effects. 1
• This intervention is specifically beneficial for mild disease with active inflammation. 1

Observation Protocol

When to Observe

• Patients with mild exophthalmos can be observed if there is no diplopia in primary gaze or reading position. 1
• The natural history is benign in 90% of patients, with gradual improvement over time. 5
• Continue observation if the clinical picture remains stable without progression to diplopia, optic neuropathy, or severe corneal exposure. 5, 6

Monitoring Parameters

• Serial exophthalmometry measurements to track proptosis progression. 4
• Visual acuity, color vision, and pupillary examination to screen for optic neuropathy. 4, 3
• Corneal examination with fluorescein staining to detect exposure keratopathy. 3
• Assessment for diplopia development or extraocular muscle restriction. 4

When to Escalate Treatment

Indications for Advanced Therapy

Escalate beyond conservative management if any of the following develop:

• Diplopia in primary gaze or reading position, indicating restrictive myopathy requiring intervention. 1
• Compressive optic neuropathy (decreased visual acuity, color vision deficits, relative afferent pupillary defect). 1, 3
• Severe corneal exposure with ulceration despite maximal lubrication. 1, 3
• Progression from mild to moderate-to-severe disease with Clinical Activity Score ≥3. 4

Advanced Treatment Options (When Indicated)

• Teprotumumab reduces proptosis and Clinical Activity Score in patients with active disease, though it carries risks including hearing impairment, hyperglycemia, and is contraindicated in pregnancy. 1, 4, 2
• High-dose pulse IV methylprednisolone for severe progression or optic neuropathy. 2, 3
• Orbital decompression surgery reserved for severe proptosis or compressive optic neuropathy unresponsive to medical therapy. 1

Common Pitfalls to Avoid

• Do not underestimate the risk of corneal exposure in mild exophthalmos—aggressive lubrication prevents irreversible corneal scarring. 3
• Do not delay smoking cessation counseling, as continued smoking dramatically worsens prognosis. 1, 4
• Do not initiate immunosuppressive therapy (steroids, teprotumumab) for truly mild disease without progression, as the natural history is benign in most cases and treatment carries significant adverse effects. 1, 5, 7
• Do not fail to establish baseline measurements (exophthalmometry, visual function) to objectively track disease progression. 4

Disease Activity Considerations

• Immunosuppressive treatments are most effective during the active inflammatory phase of disease, not for chronic stable exophthalmos. 7
• Disease activity is the main determinant of therapeutic outcome for immunosuppression in Graves' ophthalmopathy. 7
• For mild stable disease without active inflammation, observation remains superior to intervention given the 60% response rate and significant side effects of immunosuppression. 7