Masterclass 3 - Thyroid Eye Disease

Thyroid eye disease (TED) can affect quality of life even in its mild form and can possibly lead to permanent disfigurement and visual loss. It poses significant health burden in terms of individuals and public. Accurate assessment, early recognition and timely referral are keys to successful management of TED. This presentation aims to go through various assessment tools, scoring systems for activity and severity so as to enable audience to be familiarize with basic elements of TED examination. Also it aims to discuss updates in the understandings of the pathophysiology in which development of novel treatments base on.

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.

Although radiotherapy (RT) is used to treat cancers in the vast majority of cases, it is also efficacious in certain benign conditions with thyroid eye disease (TED) being a classic example. Dr Wong will briefly discuss the underlying mechanisms and the evidence for using RT in TED, as well as its role with respect to other treatment modalities in the management of this disease. He will also outline the potential adverse effects, including retinopathy and second malignancy, with the latter being a rare but much-dreaded complication. Finally, he will discuss how RT planning is done, and the multidisciplinary collaboration between different specialties at the Prince of Wales Hospital. 

The management of thyroid eye disease (TED) includes conservative treatment, topical and systemic medical therapies, optical treatment (such as Fresnel prisms or occlusion therapy for diplopia), various periocular injectables (botulinum toxin, hyaluronic acid gels, steroid), orbital irradiation, and surgical treatment. Generally speaking, surgery is indicated for more severe cases (such as refractory compressive optic neuropathy, severe proptosis with refractory exposure keratopathy, strabismus with diplopia, severe disfigurement due to proptosis and eyelid asymmetry).


In this presentation, we will discuss the more common types of surgery in TED, including orbital decompression, squint surgeries and eyelid surgeries.

Thyroid Eye Disease is the commonest orbital disorder in Hong Kong.
However, there remain huge service gaps in Hospital Authority with growing burden and affected patient population. In this masterclass on TED, experts in ophthalmology, endocrinology and oncology have shared the current status of managing TED in HK. In this final talk, "Future Development and Way Forward" we discuss the global advances in TED on screening, early detection, and management of different severity of TED.  We also highlight the unique presentations of local patient populations, challenges for local practitioners and opportunities of understanding this intriguing disorder through existing and potential multidisciplinary and multicentre networks.