Education Resource from the Society for Endocrinology

Management of disthyroid eye disease

Wilmar Wiersinga

Dept. of Endocrinology and Metabolism, Academic Medical Center, Amsterdam, The Netherlands

Summer School 11-14 July 2006
The Møller Centre, Storeys Way, Cambridge, UK

The management plan for a patient with Graves’ ophthalmopathy (GO) requires assessment of smoking behaviour, thyroid function, and eye changes in terms of activity (clinical activity score, CAS) and severity (lid aperture, soft tissue involvement, proptosis, motility, diplopia, visual acuity and colour vision).

The advice to stop smoking should be given repeatedly; even passive smoking might constitute a risk. Smokers have a less favourable outcome of immunosuppressive treatment of GO than non-smokers, and are more likely to develop recurrent Graves’ hyperthyroidism.

Restoration of euthyroidism slightly ameliorates eye changes, especially soft tissue changes and motility. 131I therapy is associated with a small risk on worsening of GO (mostly transient), especially in smokers, active GO and high TBII or TSH. Near-total thyroidectomy has no advantage over methimazole for eye changes. The effect of total thyroid ablation (thyroidectomy + 131I) is under evaluation.

Mild GO can be observed awaiting spontaneous improvement. Retrobulbar irradiation relieves orbital pain and improves motility, but is contraindicated in diabetic patients.

Very severe GO (optic neuropathy) can be treated with iv methylprednisolone (1 gram on three successive days per week for two weeks); if after two weeks the visual functions have not improved, urgent orbital decompression is indicated.

Moderately severe GO, if active (CAS =4), is currently best treated with iv methylprednisolone (500 mg/weekly for six weeks, then 250 mg/weekly for six weeks), having greater efficacy and fewer side effects than high-dose oral prednisone. Flare-ups can be managed with a combination of low-dose prednisone (20 mg per os daily) and cyclosporine. Somatostatin analogs are hardly effective; SOM-230 remains to be tested.

Thiazolidinediones might be detrimental. Promising new tools under investigation are rituximab (directed agains CD20 on B-cells), and combination treatments with prednisone, methotrexate and azathioprine.

Rehabilitative surgery comprises orbital decompression (the new swinging-eyelid technique leaves almost no scar), eye muscle and eyelid surgery, and should be done as required in this order when GO has become inactive.

The opinions expressed in this paper are those of the speaker and do not necessarily reflect the views of the Society

Revised: 24-Aug-2006