Thyroid Eye Disease Non-Surgical Management
The first phase involves treating the active eye disease. This active period can last from a few months to as many as three years.
Smoking lengthens the period of activity. Treatment during the active phase of the disease focuses on preserving sight and the integrity of the cornea as well as providing treatment for double vision when it interferes with daily functioning and becomes bothersome.
Most patients experience relief from dry eyes by using artificial tears throughout the day and gels or ointments at night. Some patients also use eye covers at night or tape their eyes shut to keep them from becoming dry if the eyelids do not close properly. Dryness occurs because the lids are retracted and cannot blink properly, because the tear-producing glands have been affected by the autoimmune process and aren’t functioning well, and/or because the forward bulging of the eyes prevents them from being completely covered by the lids.
In some cases, acute swelling causing double vision or loss of vision may be treated for a limited time with oral prednisone. However, prednisone given for more than a few weeks at the dosages required to suppress the autoimmune inflammation always causes bothersome and dangerous side-effects that may become severe. In patients who respond to prednisone, a short course of intravenous (IV) steroids (methylprednisolone) may provide symptomatic improvement with fewer side effects than oral prednisone; this is referred to as an IV steroid pulse. Surgical decompression can also be used during the active phase, most often to relieve progressive damage to the optic nerve (optic neuropathy), but sometimes it can also helpful in reducing orbital congestion, redness, pain, and eye exposure.
A newly FDA-approved drug, teprotumumab (Tepezza®, Horizon Therapeutics), has been shown to be effective in the majority of patients with active thyroid eye disease, i.e. patients who experience eye redness, pain with eye movement, worsening proptosis, and/or worsening diplopia. Teprotumumab is given by eight IV infusions over 24 weeks. It is very expensive, and requires insurance pre-authorization, but can be a very good option for some patients.
Once the disease achieves remission and the thyroid hormone levels are stabilized, treatment can focus on restoring function and correcting unacceptable changes that persist after the ocular conditions of the active phase have stabilized, such as bulging eyes (proptosis), double vision (diplopia), and eyelid malposition.
Treatment at this point is typically surgical, and needs to proceed in a predetermined order: orbital surgery first to correct the proptosis (orbital decompression), followed by eye muscle surgery to correct the diplopia, followed by eyelid surgery to improve eyelid closure and corneal protection.
It is critically important to stop smoking in order to reduce the severity and duration of thyroid eye disease.
Figure: TED can manifest with proptosis secondary to expansion of fat, seen as dark areas around the eye muscles (left image) or secondary to thickening of the eye muscles (right image).
