Thyroid Eye Disease (TED), also known as Graves’ Ophthalmopathy, is an autoimmune condition closely associated with thyroid dysfunction, most commonly Graves’ disease. The immune system mistakenly attacks the muscles and fatty tissue behind the eyes, causing inflammation and swelling. Treatment focuses on managing active inflammation to prevent permanent damage and surgically correcting structural changes once inflammation subsides. The approach depends on the disease’s severity and phase, requiring collaboration between an ophthalmologist and an endocrinologist.
Supportive Measures for Mild Symptoms
For patients with mild symptoms, the initial treatment involves conservative, non-invasive measures aimed at improving comfort and protecting the eye’s surface. Dry, gritty eyes, often due to eyelid retraction, are managed effectively with lubricating eye drops and gels. Using preservative-free artificial tears frequently and applying thicker lubricating ointments at night provides a protective barrier against corneal exposure.
Applying cool compresses helps reduce puffiness and discomfort caused by inflammation. Keeping the head elevated while sleeping helps reduce morning eyelid swelling by promoting fluid drainage. Wearing wraparound sunglasses offers protection from bright light, wind, and airborne irritants. If mild double vision occurs, an ophthalmologist may temporarily recommend a prism applied to eyeglass lenses to help fuse the images.
Medical Treatments for Active Disease
When the disease is actively inflamed, the primary goal is stopping the progression of tissue damage. Traditional treatment for moderate-to-severe active TED involves high-dose corticosteroids, often administered intravenously. These anti-inflammatory drugs suppress the immune system’s attack on orbital tissues, reducing swelling and redness. However, corticosteroids are not successful at reducing proptosis (forward bulging of the eye) and carry risks of side effects like weight gain and mood changes.
A significant advancement is Teprotumumab, a targeted biologic therapy approved specifically for active, moderate-to-severe TED. This monoclonal antibody blocks the Insulin-like Growth Factor 1 Receptor (IGF-1R), which drives inflammation and tissue expansion. Administered through eight intravenous infusions, Teprotumumab has shown efficacy in reducing proptosis and improving double vision, addressing structural issues earlier than traditional treatments.
Another localized anti-inflammatory option is orbital radiation therapy, which uses targeted, low-dose radiation beams to reduce inflammation in the orbital tissues. This treatment may be used with corticosteroids. Orbital radiation is useful when there is a risk of compressive optic neuropathy, where swollen tissues press on the optic nerve. The choice between these therapies is based on disease severity, complications, and the patient’s overall health profile.
Surgical Correction and Rehabilitation
Once the inflammatory phase of TED has subsided and the disease is stable (typically after 6 to 18 months), surgical interventions correct the remaining structural changes. These procedures are staged, addressing the most severe issues first. The first surgery performed is usually orbital decompression, designed to reduce pressure and eye bulging.
This procedure involves removing small sections of the bony orbit or excess orbital fat to create more space for the tissues. Orbital decompression protects the optic nerve from compression and improves proptosis. If double vision (diplopia) persists after decompression, eye muscle surgery (strabismus surgery) is performed next.
Eye muscle surgery adjusts the length and position of eye muscles that may have become scarred due to inflammation. The goal is to realign the eyes and increase the field of binocular single vision. The final stage is eyelid surgery, which addresses upper and lower eyelid retraction. This involves loosening retracted eyelid muscles and inserting spacer material to bring the eyelids back to a natural position, protecting the cornea and improving appearance.
Long-Term Monitoring and Follow-Up Care
Management of TED requires consistent long-term monitoring, extending beyond the active phase and surgical correction. The underlying thyroid condition, usually Graves’ disease, must be carefully controlled, as hormone fluctuations can worsen the eye disease. This control is overseen by an endocrinologist, with stable patients requiring check-ups every three to six months.
Regular follow-up with an ophthalmologist monitors disease stability and assesses treatment outcomes. Patients with mild disease may require visits every six to twelve months, while those with recent interventions need more frequent monitoring. A focus of long-term care is teaching patients to recognize signs of compressive optic neuropathy, such as changes in color vision or decreased visual acuity. Prompt recognition and intervention are necessary to prevent permanent vision loss.