Hyperthyroidism needs to be carefully controlled, preferably usually by block/replacement therapy eg carbimazole plus thyroxine. Hypothyroidism requires thyroxine replacement at a dose sufficient to suppress TSH. Patients should stop smoking as this may worsen ophthalmopathy. Remote infections (sinus or dental) should be treated appropriately.

Ophthalmopathy is otherwise treated as follows:

Active Phase

Patients with mild ophthalmopathy (Rundle a) are treated conservatively by lubrication with topical tear supplements and NSAIDs. We manage moderate cases with ocular discomfort and eyelid dysfunction (Rundle b) with oral NSAI drugs for 4-8 weeks ( eg: diclofenac 50mg tds). Some use oral steroids (e,g, 10-20mg prednisolone for 4-6 weeks).

Patients with marked disease presenting with active diplopia (Rundle c) are treated with oral prednisolone (starting with 0.5-1 mg/kg for 4 weeks and then tapering down over a further 8 weeks). Steroid-sparing agents such as azathioprine 50-150 mg/day or cyclosporin A, 5-7 mg/kg for 4-12 months are used in the treatment of complex cases with persistent diplopia. Some patients may require immunosuppression for up to two years. Orbital radiotherapy is an option for this group but is somewhat controversial.

In severe cases with optic nerve dysfunction (Rundle d) larger doses of intravenous steroid may be given (0.5-1 gram/day of methylprednisolone for 3-5 days) followed by 1mg/kg oral steroid and/or a steroid-sparing agent. This may need to be continued for several months. In cases of poor response 10 sessions of 200cGry orbital radiotherapy should be considered. In cases of persistent nerve compression, surgical orbital decompression with immunosuppression cover may be necessary1.

Stable phase (stable Mourits score for 5-6 months)

The patient’s endocrine management is reviewed. Prismatic correction is given for diplopia. Patients should refrain from smoking. Anti-inflammatory treatment may be gradually withdrawn.

Burnt out (decreased Mourits score or stable score for at least 5-6 months)

Selective or cosmetic orbital decompression (24mm proptosis or more), extra-ocular muscle surgery and finally eyelid surgery (levator recession, blepharoplasty) may be required.

1 Steel DH, Potts MJ. Thyroid Eye Disease in Easty D. Oxford Text Book of Ophthalmology 1999.(2.11.2): 722-730.

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