Update on thyroid eye disease and management

Figures & data

Figure 1 Rundle’s curve mapping increase in disease activity or severity followed by a reduction over time.

Figure 2 Severe inflammation and proptosis with classic “stare” of thyroid eye disease may be prominent in the active phase of disease.

Figure 3 Esotropia strabismus is a common manifestation of medial rectus enlargement in thyroid eye disease.

Figure 4 CT imaging of extraocular muscle enlargement at orbital apex.

Table 1 Clinical activity or severity may be assessed with either the Clinical Activity Score (CAS) or the NOSPECS severity assessment

Clinical Activity Score (CAS)
Score determined by sum of the symptoms and signs in a patient with TED at a given visit
Spontaneous retrobulbar pain
Pain on attempted up-gaze or down-gaze
Redness of the eyelids
Redness of the conjunctiva
Swelling of the eyelids
Inflammation of the caruncle and/or plica
Edema of the conjunctiva
NOSPECS Severity Assessment
Class 0	No signs or symptoms
Class 1	Only signs, no symptoms	Lid aperture (mm)
Class 2	Soft tissue involvement	Swelling, redness
Class 3	Proptosis	Exophthalmos (mm)
Class 4	Extraocular muscle involvement	Ductions (degrees), diplopia score (0, no diplopia; 1, intermittent: diplopia in primary position of gaze when tired or awake; 2, inconstant: diplopia at extremes of gaze; 3, constant: diplopia always present)
Class 5	Corneal involvement	Punctate keratopathy, ulceration
Class 6	Sight loss	Optic nerve involvement: changes in visual acuity, color vision, visual fields, or optic disk

Table 2 Proposed methyprednisolone dosing regimens

Author	Proposed methylprednisolone dosing regimen
Kahaly^Citation40	iv methylprednisolone once weekly; 0.5 g, then 0.25 g, 6 wk each (4.5 g total)
van Geest^Citation41	iv methylprednisolone 500 mg, over 3 consecutive days, in 4 cycles at 4 weekly intervals (6 g total)
Marcocci^Citation42	iv methylprednisolone; 15 mg/kg for 4 cycles and then 7.5 mg/kg for 4 cycles; each cycle consisted of 2 infusions on alternate days at 2-week intervals (9 to 12 g total)

Figures 5 (left) and 6 (right) Pre- and post-operative orbital decompression images document a marked decrease in proptosis.

Figures 7 (left) and 8 (right) Pre- and post-operative strabismus surgery images document improvement of motor alignment.

Figures 9 (left) and 10 (right) Pre- and post-operative eyelid retraction repair images document improvement of eyelid position.

KahalyGJPitzSHommelGDittmarMRandomized, single blind trial of intravenous versus oral steroid monotherapy in Graves’ orbitopathyJ Clin Endocrinol Metab20059095234524015998777

 PubMed Web of Science ®Google Scholar

Van GeestRJSasimIVKoppeschaarHPMethylprednisolone pulse therapy for patients with moderately severe Graves' orbitopathy: a prospective, randomized, placebo-controlled studyEur J Endocrinol2008158222923718230831

 PubMed Web of Science ®Google Scholar

MarcocciCBartalenaLPanicucciMOrbital cobalt irradiation combined with retrobulbar or systemic corticosteroids for Graves’ ophthalmopathy: a comparative studyClin Endocrinol (Oxf)198727133423308192

 PubMed Web of Science ®Google Scholar