Seeing all possibilities: TED management takes a team
Thyroid eye disease is not only complex physiologically, it is also heterogeneous in presentation, and its earliest signs and symptoms can be subtle or easily confused with other conditions.7 The fact that hyperthyroid treatment itself, radioactive iodine, can increase the risk for TED or exacerbate its progression only further complicates management.2 These challenges are why co-management by a partnership of endocrinologists and eye specialists is so important.
For TED itself, glucocorticoids (steroids) are the most frequently used medical therapy, despite not being indicated to treat TED. Steroids can reduce symptoms of TED, but are short-acting and do not modify underlying disease.22 Side effects can include hypertension, diabetes, bone fracture, insomnia, weight gain, and hirsutism.22-24 Potential ophthalmic side effects of steroids include cataracts and glaucoma.24 Serious risks prevent long-term steroid use and can include risk of liver failure, diabetes, and even death if large cumulative doses
(≥ 8 grams) are used.23,25
A collaborative approach between eye specialists and endocrinologists may best balance the risk/benefit profile of any medical management strategy. Once disease is inactive, this type of care team is also best suited to identifying the potential need for surgery to correct exophthalmos, strabismus, eyelid retraction, or to relieve compressive optic neuropathy.
Oculoplastic surgeon Dr. Raymond Douglas and
endocrinologist Dr. Terry Smith
describe the indispensable value of each other’s expertise when diagnosing and managing TED
Raymond Douglas, MD, PhD
Director, Orbital and
Thyroid Eye Disease
Cedars-Sinai Medical Center
Los Angeles, CA
Terry Smith, MD
Frederick G.L. Huetwell Professor
of Ophthalmology and Visual Sciences
University of Michigan
Ann Arbor, MI
Dr. Raymond Douglas:
I think a co-management approach is critical for treatment of active thyroid eye disease patients and myself as an oculoplastic surgeon. I work very closely and dynamically with endocrinologists and internists in this co-management approach of active thyroid eye disease.
Dr. Terry Smith:
I typically refer my patients to an oculoplastic surgeon once I have made the diagnosis of graves disease. I think that the baseline examinations which are uniquely performed by the oculoplastic surgeon are incredibly helpful in interpreting subsequent analysis of their signs and symptoms and I get them on board as soon as possible.
Dr. Raymond Douglas:
So I will initially see a patient for a baseline or for an initial examination and then approximately six weeks later I will see that patient for reexamination. At that point in time, either myself or it can be an ophthalmologist can really assess what kind of changes are are happening in the periorbital tissues.
Dr. Terry Smith:
The interplay between systemic disease and localized disease mandates that we are very careful in controlling the thyroid function in such patients. While such control does not cure or completely reverse the processes within the orbit.
Dr. Raymond Douglas:
A patient with active thyroid eye disease or a patient at risk with active thyroid eye disease should be monitored very closely.
Dr. Terry Smith:
The interval that I usually find comfortable is anywhere from every six weeks to every three months, depending upon the rate of progression and the severity of the disease.
Dr. Raymond Douglas:
The other aspect in co-management, I think that is important is really in the management of active thyroid eye disease and the identification of this early active window of opportunity that we see by the time patients reach the inactive phase of this disease. We're usually left with surgical options and I think as an oculoplastic surgeon and ophthalmologist, we can identify active thyroid eye disease and offer potential treatments during this window of opportunity.
Baseline exams set the stage for optimal management
A baseline eye exam should be conducted for all patients diagnosed with Graves’ disease and for all those at risk for TED. This crucial exam provides a reference point to identify the changes in clinical signs that indicate TED is active and can still be managed non-surgically. These baseline exams can be carried out by any member of a patient's care team as soon as TED is suspected, though an eye specialist should always be consulted to confirm diagnosis and aid in creating a management plan.
Key Tips for Baseline Eye Exams
For Suspected TED
Take photographs of TED signs or ask patients to provide recent photos that include facial close-ups to compare with follow-up images and detect subtle but rapid changes
Check for signs or symptoms that have worsened within the past 1-3 months, as these are important indicators of Active TED7
Include vision function as part of the baseline exam, including color vision. Changes in visual acuity, visual field, or incidence of diplopia are hallmarks of Active TED7
Ask patients about symptoms being worse during the morning or changing over the course of the day7
Adjust for racial differences when evaluating baseline exophthalmos. When doing so, bear in mind that adult female patients tend to have lower baseline measurements than adult male patients across racial groups.
Average normal exophthalmometry for male patients26
Patients at risk for TED should be monitored frequently
(e.g., every 1-3 months) for the rapid changes in signs and
symptoms that indicate Active TED.
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- Mamoojee Y, Pearce SHS. Natural History. In: Wiersinga WM, Kahaly GJ (eds): Graves’ Orbitopathy: A Multidisciplinary Approach – Questions and Answers. Basel, Karger. 2017:93-104.
- Bartley GB. The epidemiological characteristics and clinical course of ophthalmopathy associated with autoimmune thyroid disease in Olmsted County, Minnesota. Tr Am Ophth Soc. 1994;92:477-588.
- Laurberg P, Berman DC, Pedersen IB, Andersen S, Carlé A. J Clin Endocrinol Metab. 2012;92(7):2325-2332.
- Perros P, Crombie AL, Matthews JN, Kendall-Taylor P. Age and gender influence the severity of thyroid-associated ophthalmopathy: a study of 101 patients attending a combined thyroid-eye clinic. Clin Endocrinol (Oxf). 1993;38(4):367-372.
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- Kilicarsan R, Alkan A, Ilhan MM, et al. Graves’ ophthalmopathy: the role of diffusion-weighted imaging in detecting involvement of extraocular muscles in early period of disease. Br J Radiol. 2015;88(1047):20140677.
- Smith TJ, Hegedüs L. Graves’ disease. N Engl J Med. 2016;375:1552-1665.
- Villadolid MC, Yokoyama N, Isumi M, et al. Untreated Graves’ disease patients without clinical ophthalmopathy demonstrate a high frequency of extraocular muscle (EOM) enlargement by magnetic resonance. J Clin Endocrinol Metab. 1995;80(9):2830-2833.
- Rootman DB, Golan S, Pavlovich P, Rootman J. Postoperative changes in strabismus, ductions, exophthalmometry, and eyelid retraction after orbital decompression for thyroid orbitopathy. Ophthal Plast Reconstr Surg. 2017;33:289-293.
- Ponto KA, Merkesdal S, Hommel G, Pitz S, Pfeiffer N, Kahaly GJ. Public health relevance of Graves’ orbitopathy. J Clin Endocrinol Metab. 2013;98:145-152.
- Bruscolini A, Sacchetti M, La Cava M, et al. Quality of life and neuropsychiatric disorders in patients with Graves' orbitopathy: current concepts. Autoimmun Rev. 2018;17:639-643.
- Vardizer Y, Berendschot TTJM, Mourits MP. Effect of exophthalmometer design on its accuracy. Ophthal Plast Reconstr Surg. 2005;21(6):427-430.
- Maheshwari R, Weis E. Thyroid associated orbitopathy. Indian J Ophthal. 2011;60(2):88-93.
- Dolman PH. Grading severity and activity in thyroid eye disease. Ophthal Plast Reconstr Surg. 2018;34:S34-S40.
- Bartley GB, Fatourechi V, Kadrmas EF, et al. Long-term follow-up of Graves ophthalmopathy in an incidence cohort. Ophthalmology. 1996;103:958-962.
- Mitchell AL, Goss L, Mathiopoulou L, et al. Diagnosis of Graves' orbitopathy (DiaGO): Results of a pilot study to assess the utility of an office tool for practicing endocrinologists. J Clin Endocrinol Metab. 2015;100(3):E458-E462.
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- Park JJ, Sullivan TJ, Mortimer RH, Wagenaar M, Perry-Keene DA. Assessing quality of life in Australian patients with Graves' ophthalmopathy. Br J Ophthalmol. 2004;88:75-78.
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- Yang DD, Gonzalez MO, Durairaj VD. Medical management of thyroid eye disease. Saudi J Ophthalmol. 2011;25:3-13.
- Strianese D, Iuliano A, Ferrara M, et al. Methotrexate for the treatment of thyroid eye disease. J Ophthalmol. 2014;2014:128903.
- Yakopson VS, Carrasco JR, Sharma P, Rabinowitz MP, Stefanyszyn MA. Effect of intraorbital steroid injections on intraocular pressure in thyroid eye disease. Thyroid Disorders Ther. 2015;4(1):1000173.
- Gillespie EF, Smith TJ, Douglas RS. Thyroid eye disease: Towards an evidence base for treatment in the 21st century. Curr Neurol Neurosci Rep. 2012;12(3):318-324.
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