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Thyroid eye disease

Key sources
The following summarized guidelines for the evaluation and management of thyroid eye disease are prepared by our editorial team based on guidelines from the American Thyroid Association (ATA/ETA 2022), the European Thyroid Association (ETA 2022; 2018), the European Group of Graves' Orbitopathy (EUGOGO 2021), the American College of Radiology (ACR 2018), and the American Thyroid Association (ATA 2016).


1.Classification and risk stratification

Severity assessment: as per ATA 2022 guidelines, assess disease activity, severity (with particular attention to impaired ocular motility and visual loss), the trend across time, and impact on daily living in patients with TED.
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2.Diagnostic investigations

Orbital imaging
As per ATA 2022 guidelines:
Obtain orbital contrast-enhanced CT or MRI for atypical or severe cases of TED to help determine activity and to exclude other etiologies.
Obtain non-contrast CT in patients with TED considered for surgery.

3.Medical management

Management of mild orbitopathy: as per ATA 2022 guidelines, consider offering selenium selenite 100 µg BID for 6 months in patients with mild, active TED, particularly in regions of selenium insufficiency.

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  • Management of moderate-to-severe orbitopathy (first-line therapy)

  • Management of moderate-to-severe orbitopathy (second-line therapy)

  • Management of sight-threatening orbitopathy

  • Management of hyperthyroidism

4.Nonpharmacologic interventions

Smoking cessation: as per ATA 2022 guidelines, advise smoking reduction or cessation and offer support for this goal.

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  • Artificial tears

  • Ocular occlusion

  • Selenium supplementation

5.Therapeutic procedures

Local triamcinolone injections: consider performing local subconjunctival/periocular injections of triamcinolone acetate if systemic corticosteroids are absolutely contraindicated.

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  • Orbital radiotherapy

6.Specific circumstances

Pediatric patients: refer pediatric patients with eye symptoms to an orbital specialist, preferably in combined (ophthalmologist/physician) thyroid eye clinics.
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7.Patient education

General counseling
Counsel patients with moderate-to-severe and active Graves' orbitopathy explaining aims and expectations, benefits and risks of different therapies.
Select treatment for patients with moderate-to-severe and active Graves' orbitopathy based on evidence-based effectiveness, safety, evaluation of costs, reimbursement by the health system, drug availability, facilities for delivering highly specialized treatments, and personal choice of the informed patient within a shared decision-making process.

8.Preventative measures

Corticosteroid prophylaxis: as per EUGOGO 2021 guidelines, administer oral prednisone/prednisolone prophylaxis in patients treated with radioactive iodine at risk of progression or de novo development of Graves' orbitopathy (smokers, severe/unstable hyperthyroidism, high serum thyrotropin receptor antibody) with the following regimens:
high risk: 0.3-0.5 mg/kg/body weight as starting dose, tapered, and withdrawn after 3 months
low risk: 0.1-0.2 mg/kg/body weight, tapered, and withdrawn after 6 weeks.
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9.Follow-up and surveillance

Indications for referral: as per ATA 2022 guidelines, consult with an ophthalmologist when the diagnosis of thyroid disease is uncertain, in cases of moderate-to-severe TED, and when surgical intervention needs to be considered. Arrange urgent referral when sight-threatening TED is suspected or confirmed.

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  • Assessment of treatment response