Thyroid eye disease refers to the inflammatory response and its sequelae in and around the orbit in association with autoimmune thyroid disease. The condition has been recognized for more than three centuries, and has been described with various terms, such as thyroid eye disease, thyroid-associated ophthalmopathy, Graves' ophthalmopathy, thyroid orbitopathy, Graves’ orbitopathy, endocrine exophthalmos. Apart from nomenclature, many other issues such as personalized management strategies, predictors of patient response to treatment are also not yet clearly delineated.
Conventionally, self-limiting and mild thyroid eye disease is managed with supportive measures, with symptom alleviation being the primary aim of treatment. It is important to maintain euthyroidism and advise patients to quit from smoking. Selenium may be useful to slow down the disease progression. For patients afflicted with moderate to severe thyroid eye disease, highly disturbing symptoms such as proptosis and watering and grittiness of eyes, diplopia and disfigurement as well as the risk of compressive optic neuropathy demand a more aggressive approach. Because of the autoimmune and inflammatory nature of the disease, systemic steroids have been the mainstay of treatment of active disease. Other immunomodulatory agents have also been tried: Mycophenolate Mofetil has been shown to have some potential benefits; IVIG may also be effective to damp down the inflammation. Interestingly, statin therapy has been found to improve the disease outcome. With the better understanding of pathophysiology of the disease, our strategy moves towards targeted biologic therapy such as Rituximab and Tocilizumab. Teprotumumab, a human monoclonal antibody inhibitor of IGF-1R, is currently the only FDA approved medication which reduces proptosis and clinical activity score and improves quality of life. This large number of treatment modalities reflects the difficulty in treating thyroid eye disease: response is rather heterogeneous, and this complex condition definitely requires multi-disciplinary approach to optimize the treatment outcome.
