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Thyroid eye disease — Clinical Guidelines

Overview

Thyroid eye disease (TED), also known as Graves' orbitopathy, is an autoimmune condition characterized by inflammation and swelling of tissues around the eyes, potentially leading to proptosis, diplopia, and vision loss. 1 2 28

Diagnosis

Clinical Assessment: Includes evaluation of proptosis, eyelid position, extraocular movements, and signs of inflammation. 28

Imaging: CT and MRI to assess orbital fat volume, extraocular muscle involvement, and optic nerve compression. 1 14

Grading Systems: Use of the Clinical Activity Score (CAS) and the Vision Index Score (VISA) for severity assessment. 13 8

Management

First-Line Treatments:

- Glucocorticoids: Intravenous or oral glucocorticoids are often used initially, with response prediction models guiding therapy. 7 - Teprotumumab: FDA-approved monoclonal antibody targeting insulin-like growth factor-1 receptor, effective with notable safety considerations including potential hearing loss. 1 9 10 11 12

Adjunctive Treatments:

- Botulinum Toxin: Useful for managing eyelid retraction and strabismus, particularly in active disease or as a bridge therapy. 2 - Orbital Radiation: Considered for selected cases, though efficacy and safety vary. 14 - Surgical Interventions: Orbital decompression for severe cases with optic neuropathy or significant proptosis. 29 22

Special Populations

Elderly Patients: Prone to complications post-orbital decompression surgery, requiring careful preoperative assessment and multidisciplinary care. 20

Pediatrics: Limited specific data; management typically follows adult guidelines with close monitoring. 15

Pregnancy: Management strategies need to balance maternal and fetal safety, often involving conservative approaches due to limited evidence. 17

Key Recommendations

Initiate Glucocorticoids Early for Active Disease: Effective in reducing inflammation and improving symptoms. (Evidence: Strong 7)

Consider Teprotumumab for Moderate to Severe TED: Offers significant benefits but monitor for adverse effects, particularly hearing-related issues. (Evidence: Strong 1 9 10 11 12)

Use Multidisciplinary Teams for Comprehensive Care: Enhances outcomes, especially in severe cases or special populations like the elderly. (Evidence: Moderate 17 18)

Evaluate and Manage Age-Related Risks: Geriatric patients require tailored surgical and medical approaches due to increased complication risks. (Evidence: Moderate 20)

Regular Monitoring with VISA Grading: Essential for assessing disease activity and response to therapy. (Evidence: Moderate 8)

References

1 Huang W, Ou X, Lin S, Lin W, Chen G, Huang H et al.. Efficacy and Safety of Teprotumumab in Thyroid Eye Disease: A Systematic Review and Meta-Analysis. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists 2025. link 2 Zong AM, Giannakakos VP, Delbourgo Patton C, Barmettler A. Botulinum Toxin Treatment in Thyroid Eye Disease: A Systematic Review and Meta-analysis. Ophthalmic plastic and reconstructive surgery 2025. link 3 Shrestha E. A Significant Milestone in Thyroid Eye Disease Research in Nepal. Nepalese journal of ophthalmology : a biannual peer-reviewed academic journal of the Nepal Ophthalmic Society : NEPJOPH 2025. link 4 Bhatt AN, Brower D, Pan E, Ahmed A, Fei-Zhang D, Chan K et al.. A Blurry Bottom Line: The Economics of Declining Medicare Payment Trends in Ophthalmology Subspecialties, 2003 to 2024. Inquiry : a journal of medical care organization, provision and financing 2025. link 5 Wan YX, Li GQ, Duan SL, Chang S. Emerging Insights in Thyroid Eye Disease Research from 2010 to 2022: Trends, Hot Spots, and Research Situation. Seminars in ophthalmology 2025. link 6 Surl D, Ko J, Yang J, Yoon JS. A Nationwide Survey by the Korean Society of Ophthalmic Plastic and Reconstructive Surgery (KSOPRS) on the Management of Thyroid Eye Disease in South Korea. Korean journal of ophthalmology : KJO 2025. link 7 Zhang H, Wu S, Hu S, Fan X, Song X, Feng T et al.. Prediction models of intravenous glucocorticoids therapy response in thyroid eye disease. European thyroid journal 2024. link 8 Boynes AC, Enright NJ, Hardy TG, Khong JJ. Interrater reliability of photographic assessment of thyroid eye disease using the VISA classification. International ophthalmology 2024. link 9 Wang XL, Xu SS, Zhou JB, Song ZH. An observational study on the safety of teprotumumab based on FAERS database. Endocrine 2024. link 10 Huynh PP, Saba E, Rivero A, Peralta R, Liang J. A Biologic With Otologic Consequences: Analysis of Hearing Loss and Teprotumumab Using the FDA Adverse Event Reporting System. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 2024. link 11 Huang J, Su A, Yang J, Zhuang W, Li Z. Postmarketing Safety Concerns of Teprotumumab: A Real-World Pharmacovigilance Assessment. The Journal of clinical endocrinology and metabolism 2024. link 12 Zhang S, Wang Y, Qi Z, Tong S, Zhu D. Data mining and analysis of adverse event signals associated with teprotumumab using the Food and Drug Administration adverse event reporting system database. International journal of clinical pharmacy 2024. link 13 North VS, Zhou HW, Tran AQ, Godfrey KJ, Kazim M. Association of Patient Age and the Thyroid Eye Disease-Clinical Activity Score. Ophthalmic plastic and reconstructive surgery 2023. link 14 Sobel RK, Aakalu VK, Vagefi MR, Foster JA, Tao JP, Freitag SK et al.. Orbital Radiation for Thyroid Eye Disease: A Report by the American Academy of Ophthalmology. Ophthalmology 2022. link 15 Alexander JL, Wei L, Palmer J, Darras A, Levin MR, Berry JL et al.. A systematic review of ultrasound biomicroscopy use in pediatric ophthalmology. Eye (London, England) 2021. link 16 Khan SH, Malik U, Ahmed F, Siddiqui ZK, Munir S, Rashid N. Conservative Management of Thyroid Eye Disease. Journal of the College of Physicians and Surgeons--Pakistan : JCPSP 2021. link 17 Lee V, Avari P, Williams B, Perros P, Dayan C. A survey of current practices by the British Oculoplastic Surgery Society (BOPSS) and recommendations for delivering a sustainable multidisciplinary approach to thyroid eye disease in the United Kingdom. Eye (London, England) 2020. link 18 Freitag SK, Tanking T. A Nomenclature to Describe the Sequence of Visual Field Defects in Progressive Thyroid Eye Disease-Compressive Optic Neuropathy (An American Ophthalmological Society Thesis). American journal of ophthalmology 2020. link 19 Ludgate M. Cambridge Ophthalmological Symposium 2018: introduction and reflections on the day. Eye (London, England) 2019. link 20 Wu CY, Kahana A. Geriatric patients are predisposed to strabismus following thyroid-related orbital decompression surgery: A multivariate analysis. Orbit (Amsterdam, Netherlands) 2017. link 21 Bingham CM, Sivak-Callcott JA, Gurka MJ, Nguyen J, Hogg JP, Feldon SE et al.. Axial Globe Position Measurement: A Prospective Multicenter Study by the International Thyroid Eye Disease Society. Ophthalmic plastic and reconstructive surgery 2016. link 22 Perumal B, Meyer DR. Treatment of severe thyroid eye disease: a survey of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS). Ophthalmic plastic and reconstructive surgery 2015. link 23 Dagi LR, Elliott AT, Roper-Hall G, Cruz OA. Thyroid eye disease: honing your skills to improve outcomes. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus 2010. link 24 Nabipour I, Burger A, Moharreri MR, Azizi F. Avicenna, the first to describe thyroid-related orbitopathy. Thyroid : official journal of the American Thyroid Association 2009. link 25 Douglas RS, Tsirbas A, Gordon M, Lee D, Khadavi N, Garneau HC et al.. Development of criteria for evaluating clinical response in thyroid eye disease using a modified Delphi technique. Archives of ophthalmology (Chicago, Ill. : 1960) 2009. link 26 McMullen RJ, Clode AB, Gilger BC. Infrared digital imaging of the equine anterior segment. Veterinary ophthalmology 2009. link 27 Dayan CM, Dayan MR. Dysthyroid optic neuropathy: a clinical diagnosis or a definable entity?. The British journal of ophthalmology 2007. link 28 Stemberger K, Kahaly GJ, Pitz S. Update on thyroid eye disease. Comprehensive ophthalmology update 2006. link 29 Stannard L, Slater RM, Leatherbarrow B. Orbital decompression surgery for thyroid eye disease: implications for anaesthesia. European journal of anaesthesiology 2006. link 30 Denniston A, Dodson P, Reuser T. Diagnosis and management of thyroid eye disease. Hospital medicine (London, England : 1998) 2002. link 31 von Brauchitsch DK, Egbert J, Kersten RC, Kulwin DR. Spontaneous resolution of upper eyelid retraction in thyroid orbitopathy. Journal of neuro-ophthalmology : the official journal of the North American Neuro-Ophthalmology Society 1999. link 32 Small RG. Surgery for upper eyelid retraction, three techniques. Transactions of the American Ophthalmological Society 1995. link 33 Olver JM, Fells P. 'Henderson's' relief of eyelid retraction revisited. Eye (London, England) 1995. link 34 Hughes DS, Beck L, Hill R, Plenty J. Dysthyroid eye disease presenting as Brown's syndrome. Acta ophthalmologica 1993. link 35 Hollows F. Thyroid eye disease (TED)--a current understanding. Australian journal of ophthalmology 1981. link

Thyroid eye disease