Moderate-to-Severe Active Thyroid Eye Disease with Significant Proptosis or Diplopia When First-Line Therapy Has Not Met Target Outcomes

This protocol covers patients with active moderate-to-severe Graves’ orbitopathy who have significant proptosis and/or diplopia with sufficient impact on daily life to justify intervention, but who did not achieve the required response from first-line systemic therapy at 24 weeks.

Clinical Situation

Moderate-to-severe thyroid eye disease in the active phase, with significant proptosis of the eye and/or diplopia. The burden of disease is sufficient to justify the risks of intervention; this population does not have sight-threatening disease.

Why This Protocol Is Reached

First-line therapy attempted: teprotumumab, radiotherapy, intravenous glucocorticoids, or oral glucocorticoids.

Target outcomes not achieved at 24 weeks: reduction in proptosis of ≥2 mm and improvement in diplopia.

Non-achievement of both goals in the active phase leads to this next-step protocol, which is pursued once the disease has transitioned to the inactive phase.

Next-Step Approach

Once the disease becomes inactive and euthyroidism is established, this protocol involves a rehabilitative surgical approach. The specific intervention is tailored to the predominant clinical problem. Full sequencing and details are available in the structured protocol.

Clinical Goals

Restoration of binocular single vision in the primary position of gaze
Reduction of proptosis (approximately 2 mm for each orbital wall removed)

Instant Access to Structured Evidence-Based Regimens

References

doi: 10.1089/thy.2022.0251

Patients without sight-threatening disease whose eye disease has sufficient impact on daily life to justify the risks of medical or surgical intervention.
TEP is a preferred therapy, if available, in patients with active moderate-to-severe TED with significant proptosis (see Section 2.1. for definition) and/or diplopia.
The specific surgical approach should be tailored to the indication (DON, proptosis), type of orbitopathy (muscle or fat predominant congestive disease), and desired reduction in proptosis.
In patients with diplopia and inactive TED, binocular single vision in the primary position of gaze may be restored with strabismus surgery or permanent prisms ground into the spectacle lenses.
Approximately 2 mm of proptosis reduction may be expected for each wall removed or 2 cm³ of fat excision.

View source ↗