Graves ophthalmopathy; thyroid eye disease (TED)
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Epidemiology
- 5-10% of patients with Graves disease
- clinically significant ophthalmopathy in up to 50% of patients with Graves disease of which 3-5% threaten vision
- more common in smokers
- more common in patients with a family history of Graves ophthalmopathy
- more common in whites than in Asians[5]
- annual incidence: 16/100,000 women & 3/100,000 men[5]
- severe ophthalmopathy is more likely to develop in older men than in younger persons[5]
Pathology
- vison threatened by corneal breakdown & optic neuropathy
Clinical manifestations
- lid lag
- upper lid retraction
- stare
- weakness of extraocular muscles
- inflammatory changes
- periorbital edema
- chemosis
- conjunctivitis
- iritis
- sceral injection
- proptosis or exopthalmus to the point to which the lids cannot close
- optic nerve compression
- severe cases may result in optic neuropathy & blindness
- ophthalmologic signs/symptoms may or may not be present
* images[6]
Management
- consult endocrinologist & ophthalmologist
- establish euthyroid state
- methimazole is drug of choice unless pregnant[1]
- prophylthiouracil in 1st trimester
- methimazole 2nd & 3rd trimesters
- does not respond to treatment of hyperthyroidism[1]
- drug-free remission of Graves disease in 50% of patients after 2 years of treatment [1]
- methimazole is drug of choice unless pregnant[1]
- most patients require only supportive therapy[5]
- artificial tears
- glucocorticoid ophthalmic for inflammation
- selenium supplementation may be useful for mild disease[2]
- smoking cessation[1]
- teprotumumab-trbw (Tepezza) FDA-approved for treatment of proptosis
- glucorticoids for severe ophthalmopathy
- intravenously administered pulse glucocorticoid therapy
- oral glucocorticoids may have less favorable adverse-effect profile[5]
- avoid radioactive I-131 ablation of the thyroid
- worsens Graves ophthalmopathy, at least transiently
- in patients with mild-moderate Graves ophthalmopathy, prophylactic administration of prednisone is recommended prior to ablation
- MKSAP20 recommend thyroidectomy in patients with Graves ophthalmopathy
- does not mention prednisone
- thyroidectomy for severe Graves ophthalmopathy not responsive to glucocorticoids[1]
- orbital irradiation for patients not responding to glucocorticoids of uncertain long-term benefit
- orbital decompression for optic nerve compression
More general terms
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015. 2018, 2022.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025 - ↑ 2.0 2.1 Marcocci C et al. Selenium and the course of mild Graves' orbitopathy. N Engl J Med 2011 May 19; 364:1920. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21591944 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1012985
- ↑ Bahn RS. Graves' ophthalmopathy. N Engl J Med. 2010 Feb 25;362(8):726-38 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20181974
- ↑ Phelps PO, Williams K. Thyroid eye disease for the primary care physician. Dis Mon. 2014 Jun;60(6):292-8 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24906675
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Smith TJ, Hegedus L. Graves' Disease. N Engl J Med 2016; 375:1552-1565. October 20, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27797318 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMra1510030
- ↑ 6.0 6.1 Rothaus C Teprotumumab for Thyroid Eye Disease. NEJM Resident 360. Ja 22, 2020 https://resident360.nejm.org/clinical-pearls/teprotumumab-for-thyroid-eye-diseas
- ↑ Hoang TD, Stocker DJ, Chou EL, et al. 2022 Update on clinical management of Graves disease and thyroid eye disease. Endocrinol Metab Clin North Am. 2022;51:287-304. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35662442