Treatment options for thyroid eye disease.

Patients with thyroid eye disease (TED) experience hypertrophy of their extraocular muscles and an increase in intraorbital fat volume leading to eyelid retraction, proptosis, double vision, and optic nerve compression. These orbital changes are thought to be due to a cross-reaction of thyroid stimulating hormone (TSH) with antigens in the orbit. Therefore, the key to treatment is achievement of a euthyroid state in patients with abnormal thyroid function. Cigarette smoking is the strongest modifiable risk factor linked with progression and poor response to treatment. All TED patients should be counseled and offered help with smoking cessation. The treatment of TED symptoms must be customized to each patient, as the degree of orbital involvement can vary. During the active state, evaluation of sight-threatening compressive optic neuropathy and treatment of corneal exposure by an ophthalmologist is crucial to avoid irreversible damage. In most patients, local therapy with artificial tears, gels, and ointments can offer symptomatic relief of irritation and dryness. In addition, antioxidant therapy with selenium has been shown to improve quality of life in patients with mild orbital involvement. Some patients will require systemic oral or IV steroids at the onset of an active inflammatory state. However, approximately one third of patients will not be responsive to steroid therapy alone. In these patients, the addition of orbital radiation or use of immune modulation has shown value. Orbital decompression surgery should be considered for cases of vision-threatening optic neuropathy despite maximal medical therapy. Approximately 3-6 months after cessation of the active state and stabilization of symptoms, rehabilitative treatment may be offered. Treatment is offered in a 3-stage surgical approach with orbital decompression surgery, followed by strabismus surgery for any resultant binocular diplopia, and finally eyelid surgery to address eyelid retraction. Meanwhile, symptomatic diplopia may be addressed with monocular patching or prisms.