Phasing and continuity of the treatment of thyroid eye disease in patients with Graves’ disease

According to modern concepts, thyroid eye disease (TED) is an independent progressive autoimmune disease of the organ of vision, closely associated with the autoimmune pathology of the thyroid gland (TG), (ICD code — H06.2, proptosis in case of impaired thyroid function E05.0). TED treatment is a long step-by-step process, including immunosuppressive therapy, radiation therapy of the orbits and surgical treatment.

TED is a multidisciplinary problem. A patient with thyrotoxicosis clinic and TED symptoms will be taken to an endocrinological clinic for normalization of thyroid hormones and treatment of thyrotoxicosis complications. At the same time, under the supervision of an ophthalmologist, TED diagnostics and treatment will be carried out. Teamwork is of utmost importance because the effectiveness of TED treatment will depend on the speed of achieving a stable euthyroid state, the accuracy of determining the TED activity and severity, and the presence of complications requiring surgical treatment.

There are two main phases in the TED development. In the first phase of active inflammation, an increase in the symptoms of TED occurs, then a plateau phase follows, when the symptoms of activity persist but do not progress, then the symptoms regress and the process becomes inactive, while visual disturbances and cosmetic defects may persist. Determining the TED activity is very important from a clinical point of view, because the choice of treatment and tactics of patient management depend on the inflammation activity.

We describe a clinical case of phasing treatment of TED complicated by optic neuropathy and movement disorders in a patient with Graves’ disease, resistant to immunosuppressive therapy with glucocorticoids and requiring deep lateral bony orbital decompression.                                                                                                                                             

1. Bartalena L, Baldeschi L, et al. The 2016 European Thyroid Association/European Group on Graves’ Orbitopathy Guidelines for the Management of Graves’ Orbitopathy. Eur Thyroid J. 2016. doi: https://doi.org/10.1159/000443828

2. Kahaly GJ, Bartalena L, Hegedus L, et al. European Thyroid Association Guideline for the management of Graves Hyperthyroidism. Eur Thyroid J. 2018;7(4):167–86. doi: https://doi.org/10.1159/000490384

3. Свириденко Н.Ю., Шеремета М.С., Беловалова И.М., Мельниченко Г.А. Лечение болезни Грейвса при сопутствующей эндокринной офтальмопатии // Вестник офтальмологии. — 2021. — Т. 137. — №6. — С. 128–135. doi: https://doi.org/10.17116/oftalma2021137061128

4. Burch HB, Perros P, Bednarczuk T, et al. Management of Thyroid Eye Disease: A Consensus Statement by the American Thyroid Association and the European Thyroid Association. Thyroid. 2022. doi: https://doi.org/10.1089/thy.2022.0251

5. Avetisov SÉ, Grusha IaO, Ismailova DS, et al. Surgical rehabilitation of patients with thyroid eye disease: systematic approach. Vestnik Oftalmologii. 2017;133(1):4-10. (In Russ.) doi: https://doi.org/10.17116/oftalma201713314-10

6. Ismailova DS, Belovalova IM, Grusha YO, Sviridenko NY. Orbital decompression in the system of treatment for complicated thyroid eye disease: case report and literature review. Int Med Case Rep J. 2018;11:243-249. doi: https://doi.org/10.2147/IMCRJ.S164372

7. Verity DH, Rose GE. Acute thyroid eye disease (TED): Principles of medical and surgical management. Eye. 2013;27(3):308-319. doi: https://doi.org/10.1038/eye.2012.284

8. Choe CH, Cho RI, Elner VM. Comparison of lateral and medial orbital decompression for the treatment of compressive optic neuropathy in thyroid eye disease. Ophthalmic Plastic and Reconstructive Surgery. 2011;27(1):4-11. doi: https://doi.org/10.1097/IOP.0b013e3181df6a87

9. Mehta P, Durrani OM. Outcome of deep lateral wall rim-sparing orbital decompression in thyroid-associated orbitopathy: a new technique and results of a case series. Orbit. 2011;30(6):265-268. doi: https://doi.org/10.3109/01676830.2011.603456

10. Goldberg RA. The evolving paradigm of orbital decompression surgery. Archives of Ophthalmology. 1998;116(1):95-96. doi: https://doi.org/10.1001/archopht.116.1.95

11. ГGrusha YO, Fedorov AA, Kolodina AS, Sviridenko NYu. Comparative electron microscopy study of the bone surfaces after ultrasonic and mechanical high-speed bone removal in orbital decompression. Vestnik oftal’mologii. 2019;135(5-2):155-159. (In Russ.) doi: https://doi.org/10.17116/oftalma2019135052155

12. Cho RI, Choe CH, Elner VM. Ultrasonic Bone Removal Versus High-Speed Burring for Lateral Orbital Decompression: Comparison of Surgical Outcomes for the Treatment of Thyroid Eye Disease. Ophthalmic Plastic & Reconstructive Surgery. 2010;26(2):83-87. doi: https://doi.org/10.1097/iop.0b013e3181b8e614