Management of Thyroid Eye Disease: A Consensus Statement by the American Thyroid Association and the European Thyroid Association

Abstract

Thyroid eye disease (TED) remains challenging for clinicians to evaluate and manage. Novel therapies have recently emerged, and their specific roles are still being determined. Most patients with TED develop eye manifestations while being treated for hyperthyroidism and under the care of endocrinologists. Endocrinologists, therefore, have a key role in diagnosis, initial management, and selection of patients who require referral to specialist care. Given that the need for guidance to endocrinologists charged with meeting the needs of patients with TED transcends national borders, and to maximize an international exchange of knowledge and practices, the American Thyroid Association and European Thyroid Association joined forces to produce this consensus statement.

Keywords: American Thyroid Association; European Thyroid Association; consensus statement; thyroid eye disease.

FIG. 1.

Steps to Reduce Morbidity and Improve Quality of Life in Patients with TED. Measures to reduce morbidity associated with TED and improve patients' QOL. (This figure is used and adapted with permission, courtesy of the British Thyroid Foundation, from the Thyroid Eye Disease Amsterdam Declaration Implementation Group UK (TEAMeD) (https://www.btf-thyroid.org/teamed-page) and Dr. Anna Mitchell. The Thyroid Eye Disease Amsterdam Declaration is further described in references 17, 20). Abs, antibodies; GD, Graves' disease; RAI, radioiodine; TED, thyroid eye disease.

FIG. 2.

Composite of selected clinical features in patients with TED. Patient photographs provided with their consent demonstrate (a) lagophthalmos (inability to close eyelid completely); (b) edema and hyperemia of the caruncle (white arrow) and plica (black arrow) (courtesy of P. Perros); (c) chemosis (conjunctival edema) (courtesy of P. Perros); (d) lateral flare due to upper eyelid retraction (courtesy of P. Perros); (e) exposure keratopathy (courtesy of P. Perros); (f) globe subluxation. This is a rare complication in which the eye is displaced anterior to the retracted eyelids. Trapping of the globe may result in painful keratopathy or vision loss. This patient is seen at time of urgent surgery to decompress the orbits and narrow the lid aperture (courtesy of P. Dolman); (g) superior limbic keratoconjunctivitis in eye associated with marked upper lid retraction. This chronic recurring condition is often associated with thyroid disorders and is characterized by enlarged vessels and subepithelial edema involving the superior bulbar conjunctiva and corneal limbus (courtesy of P. Dolman).

FIG. 3.

Composite clinical–radiographic correlation in patients with TED. Clinical and radiographic image correlations provided with patient consent (courtesy of P. Dolman): (a, b) extraocular muscle enlargement causing periorbital soft tissue congestion, ocular motility restriction, and optic nerve compression with dysthyroid optic neuropathy; (c, d) proptosis in a patient with TED and predominant retroocular fat compartment expansion; (e, f) restricted upward gaze on the right due to right inferior rectus muscle enlargement and fibrosis; (g, h) right upper eyelid retraction and lateral flare due to enlargement and fibrosis of the right levator palpebrae superioris muscle (asterisk).

FIG. 4.

Referral guidance for patients with TED. Suggested criteria and timing for ophthalmological examination vary according to the clinical presentation of the eye disease (see Section 5.4).

FIG. 5.

Overview of the management of TED. An individualized approach to the management of TED, based on disease activity, severity, duration, trend across time, impact of the disease on daily living, treatment goals, patient age, and comorbidities, as well as the availability and relative costs of therapies, must be advised. Wherever possible, the task force members ranked therapeutic approaches as either “preferred,” “acceptable,” or “may be considered” (see Section 2.1. for definitions). See Figure 1. Except for the mildest cases improving with local measures. See Table 8. In most patients with mild TED, a “watchful monitoring” strategy is sufficient (it includes simple measures, see Section 5.1 and Fig. 1). Selected cases (with a significant decrease in QOL) may be treated as moderate-to-severe TED. In patients with symptomatic inflammatory soft tissue involvement or if radioactive iodine is used (oral glucocorticoids prophylaxis). Particularly in countries that are selenium insufficient. Standard treatment—IVGC (cumulative dose 4.5 g). In selected patients, a higher cumulative dose of methylprednisolone (7.5 g) may be considered. In patients with prominent soft tissue involvement and diplopia. In patients with a short duration of TED (< 9 months). In patients who are intolerant or resistant to IVGC. In selected patients with moderate-to-severe TED, a “watchful monitoring” strategy may be acceptable. See Section 7.3.2, and Supplementary Figure S2a, b. If there is coexistent active disease, then medical treatment as for moderate-to-severe disease is indicated in parallel with surgical treatment. High doses of IVGC (500–1000 mg of methylprednisolone) for 3 consecutive days or on alternate days during the first week. IVGC, intravenous glucocorticoid.