Management of Graves ophthalmopathy (GO) requires knowledge of smoking behaviour, thyroid function and antibodies, and activity and severity of the ophthalmopathy.
Smokers should be strongly adviced to stop smoking because outcome of Graves disease is less favourable in smokers compared to nonsmokers.
High serum concentrations of TSH receptor antibodies (TBII) are associated with a more severe and protracted course of GO. Restoration and maintenance of euthyroidism is relevant for the eyes, but how hyperthyroidism should be treated in GO patients remains controversial. Antithyroid drugs and near-total thyroidectomy are apparently neutral with respect to the course of GO, but 131I therapy carries a risk of about 15% for devleoping and/or worsening of GO. The risk can almost be neutralized by a prophylactic course of steroids, but its timing, dose and duration are ill-defined. Steroid prophylaxis should be restricted to patients who are at high risk, i.e. patients who smoke, have active GO, or high TBII.
Mild GO usually requires no treatment, but a recent randomized clinical trial demonstrated improvement of eye changes and prevention of progression to more severe GO upon treatment with selenium (100 microgram sodium selenite twice daily for 6 months). Moderate-to-severe GO if active should be treated preferably with intravenous methylprednisolone pulses (e.g. 0.5 g weekly for 6 weeks, followed by 0.25 g weekly for another 6 weeks), which are more effective and have less side effects than oral prednisone. However, intravenous methylprednisolone pulses exceeding a cumulative dose >8 gram have been associated with liver failure and cardiovascular events. In case of steroid failure, the combination of low dose oral prednisone (20 mg daily) with either cyclosporin or retrobulbar irradiation can be tried. Rituximab although still experimental- might be applied in desperate cases. Very severe GO (dysthyroid optic neuropathy) requires high-dose intravenous methylprednisolone pulses (e.g. 6 pulses of 1.0 g each, administered on alternate days); if visual functions do not improve within two weeks, an urgent surgical orbital decompression is indicated. Complete restoration of appearance and visual functions is obtained in many patients only after various surgical procedures (decompression, squint surgery, blepharoplasty), which should be done in the inactive phase of the disease.
Declaration of interest: The author declares that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.
Funding: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.