Management

Seek specialist advice.

The management of dysthyroid eye disease can be divided into immediate and longterm management.

The immediate priorities are to treat the endocrine disorder and render the patient euthyroid, prevent any visual loss and protect the cornea:

• treatment of thyroid disease (although thyroid eye disease may occur before other signs of Graves' disease and does not always respond to treatment of thyroid disease); also thyroid eye disease may occur for the first time after hyperthyroidism treatment
• artificial tears are often required for lubrication
• eyelids can be taped closed or a lateral tarsorraphy can be undertaken (stitching the eyelids together at their outer corner)
• when more active treatment is indicated, steroids are the mainstay of therapy (2)
  • high dose steroids may facilitate medical decompression of the optic nerve (visual loss may occur due to compression of the optic nerve, particularly when there is minimal exopthalmos. Optic nerve function should be assessed in terms of colour vision and the presence of any central scotomas)
• surgical decompression may be employed - this surgery utilises space in ethmoidal, sphenoidal and maxillary sinuses
• orbital radiotherapy - this treatment modality is increasingly utilised at an early stage in management of thyroid eye disease
• a Fresnel prism stuck to one lens of a spectable may be used in the management of diplopia - this lens is changed with respect to changes in exophthalmus

Longterm management aims to restore external ocular muscle function and restore appearance.

Notes:

• there is evidence that thyroid eye disease may occasionally be made worse by treatment with radioiodine (1,2)
• treatment with bromocriptine, somatostatin analogues, plasmapharesis and acupuncture have been suggested for the management of this condition but a role for these agents requires confirmation (1)
• orrbital radiotherapy improves the efficacy of glucocorticoids, but is probably less beneficial as monotherapy (2)
• orbital surgery is best reserved for patients with 'burnt out' inactive disease, but urgent orbital decompression may be required for optic neuropathy (2)
• thyroid-eye disease generally goes into spontaneous remission with time (1). In most patients, thyroid eye disease is self-limiting and no specific treatment is required (2)

Reference:

1. Lancet 2001; 357 (9270): 1793-6.
2. El-Kaissi S et al. Thyroid-associated ophthalmopathy: a practical guide to classification, natural history and management. Int Med Journal 2004; 34(8):482-491