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  • Review Article
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Management of Graves' ophthalmopathy

Nature Clinical Practice Endocrinology & Metabolism volume 3, pages 396–404 (2007)Cite this article

Abstract

Management of Graves' ophthalmopathy is preferably done in a multidisciplinary setting. Smoking is associated with worse disease outcome. 131I therapy for hyperthyroidism can also worsen ophthalmopathy, especially if administered during active disease or to patients who smoke or have severe hyperthyroidism, or those with high levels of TSH-receptor-binding inhibitory immunoglobulins. Coadministration of steroids and 131I therapy is recommended for such high-risk patients. 131I therapy is safe for patients with inactive Graves' ophthalmopathy. Subtotal thyroidectomy and antithyroid drugs show no benefit or harm to eye changes. There is no good evidence that total thyroid ablation has additional benefit. Artificial teardrops, dark glasses and prisms are very helpful. Dysthyroid optic neuropathy is best treated with intravenous pulsed methylprednisolone; if visual functions do not recover, urgent surgical decompression is indicated. A wait-and-see policy is recommended in mild Graves' ophthalmopathy because the natural history of this condition reveals a tendency to resolve spontaneously. Active, moderately severe Graves' ophthalmopathy qualifies for immunosuppression: intravenous pulsed methylprednisolone is more efficacious and has fewer side effects than oral steroids. Once the disease is inactive, rehabilitative surgery has much to offer. Quality of life is seriously limited in patients with Graves' ophthalmopathy, and remains restricted even after all treatments. Consequently, there is an urgent need for improved treatment modalities, and antibody therapy has shown promise in this respect.

Key Points

  • Management of Graves' ophthalmopathy should be tailored to the individual patient's needs, but requires assessments of smoking behavior, thyroid function, and the severity and activity of the eye changes

  • Cessation of smoking is useful in the primary, secondary and tertiary prevention of Graves' ophthalmopathy

  • Treatment of Graves' hyperthyroidism with antithyroid drugs or subtotal or near-total thyroidectomy has no risk or benefit with respect to Graves' ophthalmopathy, but 131I therapy carries a small risk of development or worsening of eye changes

  • Mild Graves' ophthalmopathy is best managed by a 'wait-and-see' policy or retrobulbar irradiation, whereas dysthyroid optic neuropathy should be treated urgently with intravenous pulsed methylprednisolone

  • Active, moderately severe Graves' ophthalmopathy qualifies for immunosuppression; the efficacy and tolerability of intravenous pulsed methylprednisolone are better than those of high-dose oral prednisone

  • Rehabilitative surgery (in the sequence orbital decompression, eye-muscle surgery, eyelid surgery) should be considered in patients who have residual eye changes once Graves' ophthalmopathy has become inactive

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Figure 1: European Group on Graves' Orbitopathy recommendations for assessment of Graves' ophthalmopathy6
Figure 2: The natural history of Graves' ophthalmopathy, and the effect of immunosuppression
Figure 3: Management of Graves' ophthalmopathy

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Authors and Affiliations

  1. WM Wiersinga is a Professor of Endocrinology in the Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, The Netherlands.,

    Wilmar M Wiersinga

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Correspondence to Wilmar M Wiersinga.

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Wiersinga, W. Management of Graves' ophthalmopathy. Nat Rev Endocrinol 3, 396–404 (2007). https://doi.org/10.1038/ncpendmet0497

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