Treatment of Graves' orbitopathy (ophthalmopathy)
- Terry F Davies, MD, FRCP, FACE
Terry F Davies, MD, FRCP, FACE
- Baumritter Professor of Medicine
- Icahn School of Medicine at Mount Sinai
Graves' orbitopathy (ophthalmopathy) is an autoimmune disease of the retro-orbital tissues. This topic review will provide an overview of the treatment of this disorder; its pathogenesis and clinical features are discussed separately. (See "Pathogenesis and clinical features of Graves' ophthalmopathy (orbitopathy)".)
In some patients, orbitopathy changes little for many years. In others, it may worsen or improve or, in a few patients, follow a course characterized by exacerbations and remissions. These variations make it especially difficult to reach conclusions about the efficacy of treatment. (See 'Efficacy' below.)
One study, as an example, evaluated 237 patients with newly diagnosed Graves' hyperthyroidism who were treated with thionamides . At initial presentation, the majority (73.7 percent) of patients had no ocular involvement, whereas mild, moderate-to-severe, and sight-threatening orbitopathy were present in 20, 5.8, and 0.3 percent of patients, respectively. During the 18-month follow-up period, progression to moderate-to-severe orbitopathy occurred in 2.6 percent of patients with no orbitopathy at baseline and in 2.4 percent of patients with mild activity at baseline. In contrast, 58 percent of patients with mild disease at baseline experienced complete remission.
APPROACH TO TREATMENT
Treatment of patients with Graves' orbitopathy includes:
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- Salvi M, Vannucchi G, Campi I, et al. Efficacy of rituximab treatment for thyroid-associated ophthalmopathy as a result of intraorbital B-cell depletion in one patient unresponsive to steroid immunosuppression. Eur J Endocrinol 2006; 154:511.
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- NATURAL HISTORY
- APPROACH TO TREATMENT
- Reversal of hyperthyroidism, if present
- - Effect of hyperthyroidism therapy on orbitopathy
- Reduction of thyroid hormone synthesis
- Direct effect of type of therapy
- - Choice of hyperthyroidism therapy in patients with orbitopathy
- Smoking cessation
- Local measures
- Additional treatment according to severity of orbitopathy
- - Mild symptoms
- - Moderate-to-severe or progressive symptoms
- - Sight threatening
- Medical therapies
- - Selenium
- - Glucocorticoid therapy
- - Rituximab
- - Ineffective medical therapies
- External orbital radiation
- Orbital decompression surgery
- - Timing of surgery
- - Other operations
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS