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Variation in treatment of thyroid eye disease

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Thyroid eye disease (TED) is the result of inflammation of the eyes, the eye muscles and the surrounding tissues. It is called TED because it is most often associated with autoimmune thyroid disease, specifically Graves’ disease. However, it can also be seen in patients with Hashimoto’s thyroiditis and in patients with normal thyroid function but positive thyroid antibodies. While mild changes related to TED can be seen using sensitive imaging equipment in many patients with Graves’ disease, clinical symptoms are only seen in ~5% of patients. Symptoms of TED can range from dry eyes and red eyes to significant bulging of the eyes and double vision and can be very disfiguring. Even mild symptoms can affect patients’ well-being while severe cases can impact vision. Treatment varies according to both severity and treatments available and include steroids, immune suppressing drugs, selenium, radiation and surgery. A major advance in treatment is the new drug Tempezza (teprotumumab) which often results in marked improvement to resolution of symptoms. This study was done to survey Endocrinologists from the US and Europe to compare diagnosis and treatment of TED.

Brito JP et al 2022 A survey on the management of thyroid eye disease among American and European Thyroid Association members. Thyroid 32:1535–1546. PMID: 35946071.

An electronic questionnaire was sent to members of the American and European Thyroid Associations in June, 2021. There were 227 respondents (58.1% from Europe, 27.3% from North America, and 14.5% from other locations). Questions included aspects of diagnosis and treatment of TED, using patient examples. Responses were grouped into three general areas (North America, Europe, and other regions including Central and South America, Asia and Asia Pacific). Results were separated according to severity of disease.

For mild disease, smoking cessation and artificial tears was recommended by over 65% of respondents. European respondents were more likely to use selenium for mild TED. For patients with moderate-to-severe TED, North American respondents tended to prefer Tempezza initially, while European clinicians preferred steroids (usually administered intravenously). Radiation therapy to the eyes or the use of the immune suppression drug rituximab was recommended by less than 5% of respondents for patients with moderate-to-severe TED. Over 50% of respondents did not have a multidisciplinary team of specialists to treat patients with TED. Overall, 80% said they would refer a patient to an ophthalmologist after diagnosing or suspecting TED. When treating moderate to severe TED, 30% would order an orbital MRI and 20% would use an orbital CT. One third said the financial cost of evaluation and treatment of TED was a major concern. Respondents preferred antithyroid medications for treatment of associated hyperthyroidism with surgery and radioactive iodine less often used.

Treatment of TED varies by region. This can represent differences in guidelines from medical societies and insurance/governmental financial support. It points out the importance of multidisciplinary teams in caring for patients with TED. However, since most of the respondents were from academic institutions, results may not generalize to real-life clinical situations. For patients, it is important to recognize that there are multiple avenues to treatment of TED and to request consultation in moderate to severe cases.

— Marjorie Safran, MD


Thyroid eye disease (TED): also known as Graves ophthalmopathy. TED is most often seen in patients with Graves’ disease but also can be seen with Hashimoto’s thyroiditis. TED includes inflammation of the eyes, eye muscles and the surrounding tissues. Symptoms include dry eyes, red eyes, bulging of the eyes and double vision.

Multidisciplinary team: a group of specialists, often including surgeons, radiologists, oncologists and endocrinologists, that work together to prove the best medical treatment to patients

Graves’ disease: the most common cause of hyperthyroidism in the United States. It is caused by antibodies that attack the thyroid and turn it on.

Autoimmune thyroid disease: a group of disorders that are caused by antibodies that get confused and attack the thyroid. These antibodies can either turn on the thyroid (Graves’ disease, hyperthyroidism) or turn it off (Hashimoto’s thyroiditis, hypothyroidism).

Hashimoto’s thyroiditis: the most common cause of hypothyroidism in the United States. It is caused by antibodies that attack the thyroid and destroy it.