|LETTER TO THE EDITOR
|Year : 2011 | Volume
| Issue : 3 | Page : 151-152
Shopping for doctors: Thyroid eye disease patients are never satisfied
Haitham H Al Mahrouqi
Department of Preventive and Social Medicine, University of Otago, Christchurch, NewZealand
|Date of Web Publication||29-Dec-2011|
Haitham H Al Mahrouqi
4/107 Deans Ave, Riccarton, Christchurch, 8011
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Al Mahrouqi HH. Shopping for doctors: Thyroid eye disease patients are never satisfied. Oman J Ophthalmol 2011;4:151-2
In all specialities of medicine, there are some conditions in which achieving patient satisfaction is rather difficult. These patients keep shopping for doctors! In ophthalmology, thyroid eye disease (TED) is a typical example.
TED (synonymous with thyroid orbitopathy or Graves' ophthalmopathy) is an organ-specific autoimmune condition associated with Graves' disease due to a common autoantibody.  TED may precede, coincide with, or follow the clinical onset of Graves' disease. Smoking is a major risk factor for developing TED after a diagnosis of Graves' disease, and thus smoking cessation is pertinent for primary prevention.
Patients in their middle ages and at the peak of their careers no doubt find TED extremely distressing. The disfiguring nature of proptosis and the serious and permanent complications of TED can be disabling. Acknowledging the widespread suboptimal management of TED, the European Group on Graves' orbitopathy (EUGOGO) recently published an evidence-based consensus on the optimal management of TED. 
| Management of Thyroid Eye Disease|| |
Primary care physicians should refer all TED patients except for mild cases (see below) to an ophthalmologist.
On initial presentation, ophthalmologists should stage the activity and grade the severity of the disease. The activity of the disease is scored according to the "clinical activity score"  Three or more out of the following seven signs and symptoms indicate active disease:
- Spontaneous retrobulbar pain
- Pain on attempted vertical gaze
- Redness of the eyelids
- Redness of the conjunctiva
- Swelling of the eyelids
- Inflammation of the caruncle and/or plica
- Conjunctival edema
- (Active if ≥3/7)
The EUGOCO recommends the following classification for the severity of TED: 
- Sight-threatening: Patients with dysthyroid optic neuropathy (DON) and/or corneal breakdown.
- Moderate-to-severe: Patients without sight-threatening TED whose eye disease has sufficient impact on daily life to justify the risks of immunosuppression (if active) or surgical intervention (if inactive).
- Mild: patients whose features of TED have only minor impact on daily life insufficient to justify immunosuppressive or surgical treatment.
Initially, restoring euthyroidism, smoking cessation, and the use of lubricants are vital in the management of TED [Figure 1].
For both moderate to severe and sight-threatening TED, randomised controlled trials have shown that pulsatile administration of intravenous glucocorticosteroids (GCs) is better than oral therapy due to lesser side effects and faster onset. 
There is some conflict as to whether orbital radiotherapy (OR) is effective in treating moderate to severe TED.  The EUGOGO recommends consideration of OR in moderate to severe TED with diplopia and restricted eye mobility but do not recommend it as a first line treatment for sight-threatening TED. Combination of high-dose oral GCs and OR were found to be more effective than either treatment alone, especially with regard to soft tissue swelling and diplopia. , However, there is a lack of evidence as to whether combining OR with intravenous GCs is superior to intravenous GCs alone.
The EUGOGO recommends the following sequence of rehabilitative surgery: orbital decompression, then squint surgery, and then lid lengthening with or followed by blepharoplasty/browplasty. Surgery is only recommended at least 6 months after inactive disease.
With new advances in the management of TED, other therapeutic agents such as immunosuppressants, intravenous gammaglobulins, and biological agents may have a role in the future.
| References|| |
|1.||Khoo TK, Bahn RS. Pathogenesis of Graves' ophthalmopathy: The role of autoantibodies. Thyroid 2007;17:1013-8. |
|2.||Bartalena L, Baldeschi L, Dickinson A, Eckstein A, Kendall-Taylor P, Marcocci C, et al. Consensus statement of the European Group on Graves' orbitopathy (EUGOGO) on management of GO. Eur J Endocrinol 2008;158:273-85. |
|3.||Rose GE. Clinical activity score as a guide in the management of patients with Graves' orbitopathy. Clin Endocrinol (Oxf) 1997;47:15. |
|4.||Marcocci C, Bartalena L, Bogazzi F, Bruno-Bossio G, Lepri A, Pinchera A. Orbital radiotherapy combined with high dose systemic glucocorticoids for Graves' ophthalmopathy is more effective than radiotherapy alone: Results of a prospective randomized study. J Endocrinol Invest 1991;14:853-60. |
|5.||Bartalena L, Marcocci C, Chiovato L, Laddaga M, Lepri G, Andreani D, et al. Orbital cobalt irradiation combined with systemic corticosteroids for Graves' ophthalmopathy: Comparison with systemic corticosteroids alone. J Clin Endocrinol Metab 1983;56:1139-44. |