Appendix 3 .uk
LEEDS TEACHING HOSPITALS TRUST
eClinical Guidelines Template
|TITLE Referral, Assessment and Treatment of Thyroid Eye Disease (TED) |
|Guideline Detail |
|Publication date: June 2023 |
|Next Review date: June 2026 |
|Status: CURRENT |
|Contents |
|Background |
|Diagnosis |
|Establishing a diagnosis |
|Differential diagnosis |
|Assessing clinical activity |
|Assessing Severity |
|When to refer to Joint Thyroid-eye disease clinic |
|Urgent referral |
|Routine referral |
|Investigations |
|Treatment and Management |
|General principles algorithm |
|Mild disease |
|Moderate and severe disease |
|Radiotherapy |
|Surgical intervention |
|Systemic immune suppressants and Biologics |
|Summary of Guideline |
|Please ensure that you include a summary which may include the following: |
|Patients with all but the mildest of thyroid eye (TED) disease benefit from being managed in a joint endocrine/eye clinic. |
|Patients can present with a variety of symptoms and signs ranging from swelling of the soft tissues around the eyes to ocular surface |
|discomfort, diplopia and orbital pain. |
|The degree of activity of a patient’s thyroid eye disease is determined by the clinical activity score (CAS). Patients scoring 3 or above are |
|generally deemed to be active. The severity of the eye disease can then be classified on the basis of lid retraction, exophthalmos, soft |
|tissue signs around the eye, corneal involvement and diplopia. Rarely patients may be at risk of sight loss, principally from dysthyroid optic|
|neuropathy or corneal exposure. |
|Treatment and management of the disease is aimed at controlling the active inflammatory phase before dealing with the long term sequelae of |
|the disease such as lid malposition and strabismus. Steroids form the mainstay of treatment of the active inflammatory component although |
|radiotherapy and surgery may be useful adjuncts. Novel therapies including anti TNFα and monoclonal antibody agents remain promising but lack |
|a proven evidence base at present. |
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|Aims |
|To improve the diagnosis and management of Thyroid Eye Disease (TED) |
|Objectives |
|To provide evidence-based recommendations for appropriate diagnosis, investigation and management of Thyroid Eye Disease |
|Background |
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|Glossary of terms |
| |
|TED: Thyroid eye disease |
|DON: Dysthyroid optic neuropathy |
|GO: Graves ophthalmopathy/orbitopathy |
|PPI: Proton pump inhibitor |
|CAS: Clinical activity score |
| |
|Thyroid-eye disease, or dysthyroid-associated orbitopathy is a disease of the eyes and surrounding soft tissues. |
|It is an autoimmune inflammatory disorder affecting the tissues within the eye socket, characterised by pain, swelling, redness, watering, |
|retraction of the upper eyelids, conjunctivitis, bulging eyes, double vision and, in rare circumstances, decreased vision. |
| |
|Thyroid-eye disease may occur before or after the onset of overt thyroid disease, and can start suddenly or more slowly. The yearly incidence |
|is 16/100,000 in women, 3/100,000 in men, and the disease is more frequent in smokers. |
| |
|Although patients may undergo spontaneous remission of symptoms within a year, many still need treatment. The first step of treatment aims to |
|regulate thyroid hormone levels and a block and replace regime is often used for this. It is imperative that patients cease smoking. Topical |
|treatments such as lubricating eye drops can be used to alleviate symptoms in very mild disease. |
| |
|In more active disease, signs or symptoms increase. In most cases steroids are effective but are used conservatively because of their side |
|effects. In severe cases the vision may be threatened due to optic nerve compression or corneal ulceration related to lagophthalmos and |
|exposure. About 3-5 % of patients have severe disease which may need treatment urgently with high dose intravenous steroids and/or surgery for|
|refractory cases. |
| |
|Management of the active stage of the disease may take several years. Following this, patients may be left with numerous sequelae including |
|double vision, protruding eyes, eye bags and lid retraction. Many of these aspects of the patient’s appearance are amenable to surgery but |
|this is undertaken in a step-wise process and again may take a long time to complete. |
| |
|Thyroid-eye disease is a rare but treatable disease that causes a significant decrease in quality of life. In all but the very mildest of |
|cases patients benefit from a multi-disciplinary approach and should be managed in specialised clinics with endocrine, ophthalmic and |
|orthoptic expertise. It is hoped that this document will improve the referral of patients into our joint clinics so that patient’s treatment |
|and outcomes can be optimised and unnecessary follow-up minimised. |
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|Diagnosis |
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|Establishing a diagnosis and assessing the activity of thyroid eye disease |
| |
|Patients with thyroid eye disease may present with any number of the signs and symptoms outlined below: |
| |
|Redness of the eyelids and conjunctivae |
|Swelling of the lids |
|Swelling of the conjunctivae (chemosis) |
|Swelling of the carruncle (the fleshy lump of tissue at the nasal aspect of the eyelids) |
|Lid retraction and scleral show |
|Signs of corneal exposure |
|Puffy eyelids |
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|Eye pain at rest |
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|Pain on eye movements |
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|Double vision |
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|Itchy / Burning / Stinging eyes |
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|Other conditions that may present in a similar fashion should form part of your differential diagnosis: |
| |
|Allergic Conjunctivitis |
|Myasthenia Gravis |
|Orbital mass |
|Orbital Pseudotumour |
|Carotico-cavernous fistula |
|Orbital Myositis |
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|Once a diagnosis of thyroid-eye disease has been established then a rational approach to treatment should be pursued. The first stage is to |
|establish the degree of inflammatory activity using the clinical activity score outlined below: |
| |
|Components of the clinical activity score |
| |
|Spontaneous retrobulbar pain |
|Pain with eye movement |
|Redness of the eyelids |
|Redness of the conjunctiva |
|Swelling of the eyelids |
|Swelling of the caruncle |
|Conjunctival oedema (chemosis) |
| |
|A score is given out of 7 with each component scoring 1 point |
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|The severity of disease can then be assessed using the following algorithm: |
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|Features of Mild and Moderate-to-Severe Graves’ Ophthalmopathy |
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|Mild |
|Moderate-to-severe |
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|Characteristic |
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|Eyelid retraction (mm) |
| ................
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