Thyroid surgery for treatment of Graves’ disease complicated by ophthalmopathy: a comprehensive review

Abstract

Graves’ disease (GD) is an autoimmune disorder in which antibodies directed against thyroid-stimulating hormone receptors leads to thyrotoxicosis. Graves’ ophthalmopathy, a condition that occurs in up to half of GD patients, is a cause of significant morbidity and is potentially vision threatening. Three treatment options are equally effective for uncomplicated GD and these include thyroid surgery (thyroidectomy), radioactive iodine thyroid ablation and antithyroid drugs. However, recent practice surveys suggest that surgery is the least favored GD treatment. When GD is complicated by moderate-to-severe Graves’ ophthalmopathy, antithyroid drugs and surgery are recommended by current guidelines, and again the preference for thyroid surgery in these cases has remained low. This report aims to review current published data regarding thyroidectomy as a treatment for GD, and in particular, we focus on the effects of thyroidectomy on Graves’ ophthalmopathy development and progression.

Keywords:

• eye disease
• Graves’ disease
• ophthalmopathy
• thyroid surgery
• thyroidectomy

Acknowledgements

We would like to thank K Ong for her administrative support in the preparation of this manuscript.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Graves’ ophthalmopathy (GO) occurs in up to half of the patients who are diagnosed with Graves’ disease, is the cause of significant morbidity and is potentially sight threatening.

• Current guidelines recommend that for mild active GO, radioactive iodine with concomitant steroids, antithyroid drugs (ATD) and thyroid surgery (thyroidectomy) are equally acceptable treatment options, and for moderate-to-severe or sight-threatening GO, ATD or thyroidectomy is recommended.

• Despite these recommendations, surveys of current clinical practice trends suggest that surgery is under-utilized, especially in the presence of GO.

• Over the past several decades, reports evaluating the morbidity associated with thyroidectomy have shown that its complication rates are low and that thyroidectomy may be the most cost–effective treatment for Graves’ disease when compared radioactive iodine and ATD.

• Multiple systematic reviews and meta-analyses have found that total thyroidectomy is the preferred thyroid operation for the treatment of Graves’ disease, as it has similar complication rates to subtotal thyroidectomy, and predictably results in hypothyroidism that can then be effectively treated.

• Regardless of the extent of the operation, thyroidectomy leads to regression of GO while radioactive iodine or ATD may have a negative or neutral effect on GO outcome.

• Total thyroid ablation may have additional benefits with respect to GO outcomes when compared to total thyroidectomy alone, but further study is needed.