Updates in the Management of Thyroid Eye Disease
Abstract
Introduction: Thyroid eye disease (TED) is an extrathyroidal manifestation of autoimmune thyroid diseases such as Graves’ disease (GD) and Hashimoto’s thyroiditis. TED frequently causes severe, sight‑threatening symptoms requiring prompt medical or surgical intervention. Recent therapeutic advances are revolutionizing TED treatment, prompting an updated review on TED management.
Epidemiology and Classification: The estimated incidence of TED is 4.2/100,000 population/year, with a female-to-male ratio of 3.7:1. Risk factor control includes maintaining euthyroid function, smoking cessation and steroid prophylaxis following radioactive iodine therapy. The European Group on Graves’ Orbitopathy (EUGOGO) denotes TED severity, whereas the clinical activity score (CAS) describes disease activity.
Medical and Surgical Management: Mild TED is treated conservatively using ophthalmic lubricants, selenium supplementation, cold compresses, and head elevation. Intravenous glucocorticoids are first‑line for sight-threatening and moderate-to-severe TED with low activity, and for patients experiencing pain and discomfort with moderate-to-high activity, without sight-threatening symptoms. Newer targeted therapies for moderate-to-severe TED, such as teprotumumab, have promising outcomes, although exact therapeutic indications require further investigation. Surgery is indicated in refractory hyperthyroidism, sight-threatening keratopathy, optic neuropathy, and fibrotic disease. Interventions include total thyroidectomy, orbital decompression, strabismus correction, eyelid surgery, and aesthetic considerations. Patients require close follow-up with reclassification of CAS and EUGUGO severity at each visit to address refractory disease early.
Conclusions: TED is a severe extrathyroidal manifestation of autoimmune thyroid diseases, requiring precise disease stratification and longitudinal monitoring for optimal outcomes. Continued refinement of treatment algorithms is essential to improving long-term outcomes. Real-world data on emerging treatments will be critical in determining the future management of patients requiring intervention.
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