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Thyroid Eye Disease OG

Thyroid Eye Disease

Management of Thyroid Eye Disease

Raymond Douglas, MD, PhD 
Reviewed on September 30, 2025

Management Overview

Management of thyroid eye disease (TED) has historically been based on broad-acting pharmacological agents with varying efficacy. In the contemporary era, TED management is moving toward the application of targeted treatments (eg, teprotumumab) and treatment individualization. Before any treatment is initiated, patients with TED should be assessed for disease activity (using the clinical activity score or vision, inflammation/congestion, strabismus/motility and appearance/exposure [VISA] inflammation score), severity (using the European Group on Graves’ Orbitopathy or VISA classification) and trend across time in both activity and severity (see Presentation and Diagnosis for more detail). The impact of TED on patients’ quality of life should also be assessed — see Surgical and Supportive Management.

This section provides a general overview of the indications, and safety and efficacy data, for pharmacotherapies used in TED management. Specific recommendations on when…

Management Overview

Management of thyroid eye disease (TED) has historically been based on broad-acting pharmacological agents with varying efficacy. In the contemporary era, TED management is moving toward the application of targeted treatments (eg, teprotumumab) and treatment individualization. Before any treatment is initiated, patients with TED should be assessed for disease activity (using the clinical activity score or vision, inflammation/congestion, strabismus/motility and appearance/exposure [VISA] inflammation score), severity (using the European Group on Graves’ Orbitopathy or VISA classification) and trend across time in both activity and severity (see Presentation and Diagnosis for more detail). The impact of TED on patients’ quality of life should also be assessed — see Surgical and Supportive Management.

This section provides a general overview of the indications, and safety and efficacy data, for pharmacotherapies used in TED management. Specific recommendations on when to apply each treatment option are discussed in Treatment Guidelines. A suggested management algorithm is presented in Figure 4-1. Surgical management of TED is discussed in Surgical and Supportive Management.

Enlarge Figure 4-1: Algorithm for the management of TED: Modified from: Wiersinga WM, et al. <em>Lancet Diabetes Endocrinol</em>. Published online May 2, 2025. doi:10.1016/S2213-8587(25)00066-X.
Figure 4-1: Algorithm for the management of TED: Modified from: Wiersinga WM, et al. Lancet Diabetes Endocrinol. Published online May 2, 2025. doi:10.1016/S2213-8587(25)00066-X.

General Management

Local ocular measures and lifestyle changes form the basis of the general management of TED, regardless of severity.

Corneal exposure and dry eye symptoms can be prevented or managed with lubricant drops and eye masks, while diplopia may be reduced or corrected with ocular occlusion or prisms. Topical glucocorticoid drops may be used if there is evidence of focal eye inflammation but are in most cases not helpful in TED. Smoking cessation (or, at a minimum, reduction) should be strongly encouraged.

References

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  • Bartalena L, Kahaly GJ, Baldeschi L, et al. The 2021 European Group on Graves' orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves' orbitopathy. Eur J Endocrinol. 2021;185(4):G43-G67.
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  • Lanzolla G, Maglionico MN, Comi S, et al. Sirolimus as a second-line treatment for Graves' orbitopathy. J Endocrinol Invest. 2022;45(11):2171-2180.
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  • van Geest RJ, Sasim IV, Koppeschaar HP, et al. Methylprednisolone pulse therapy for patients with moderately severe Graves' orbitopathy: a prospective, randomized, placebo-controlled study. Eur J Endocrinol. 2008;158(2):229-237.
  • Viridian Therapeutics Announces Positive Long-Term Durability Data from the Veligrotug Phase 3 THRIVE Clinical Trial in Patients with Active Thyroid Eye Disease (TED). https://investors.viridiantherapeutics.com/news/news-details/2025/Viridian-Therapeutics-Announces-Positive-Long-Term-Durability-Data-from-the-Veligrotug-Phase-3-THRIVE-Clinical-Trial-in-Patients-with-Active-Thyroid-Eye-Disease-TED/default.aspx.
  • Wiersinga WM, Eckstein AK, Žarković M. Thyroid eye disease (Graves' orbitopathy): clinical presentation, epidemiology, pathogenesis, and management. Lancet Diabetes Endocrinol. 2025;13(7):600-614.
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