Focusing on TED: Rare but devastating

Reviewed by Gary Lelli, MD

Thyroid eye disease (TED) is a rare autoimmune condition that is associated with Graves disease and is vision-threatening, making its identification all the more important, according to Gary Lelli, MD, vice chairman of ophthalmology at Weill Cornell Medical College in New York, New York.

Although this association is recognized, TED and Graves disease are 2 separate entities. “The TED component,” Lelli said, “can occur in up to 50% of patients with Graves disease, but also in hypothyroid and normal thyroid levels.”

In addition, TED occurs much more often in women—that is, as much as 5 times more often—and more in the fourth decade of life. A second peak can occur in older patients in their sixth decade of life.

In addition, smokers are much more likely to develop TED and have a longer period of inflammation from TED as well as a more severe disease course. The inflammation that develops in TED around the eye and eye socket can cause progressive changes, resulting in functional vision disorders, patient discomfort, and changes in patient appearance over relatively short periods of weeks to months, Lelli explained.

A menu of symptoms accompanies TED, such as severe dry eye, ocular redness and irritation, ocular bulging, eyelid retraction, and blurry vision. The characteristic inflammation associated with TED can impact the ocular muscles, resulting in diplopia and a detrimental effect on daily activities, such as reading and driving.

In the most severe cases, inflammation can cause compression of the optic nerve, resulting in visual loss. This most severe result can occur in approximately 2% to 5% of patients. Inflammation also can affect the normal fat behind the eyes and cause hypertrophy. This scenario is involved with ocular bulging. Swelling that is related to the fat hypertrophy also can be apparent in the lower and upper eyelids.

The TED team

Lelli emphasized that an evaluation conducted by the appropriate specialist is the most important factor in diagnosing and managing this patient population. A history of any thyroid imbalance, especially a history of Graves disease, should signal an evaluation by an oculoplastic surgeon or a neuro-ophthalmologist.

Early treatment and putting a team of clinicians in place that includes—in addition to the oculoplastic surgeons and neuro-ophthalmologist—an endocrinologist, a strabismus specialist, and in some cases a psychiatrist or psychologist to assist with the emotional problems that accompany drastic changes in appearance are most beneficial, Lelli advised.

Early treatment steps

Because TED has a variety of presentations, the first step is categorization of the patient regarding the disease stage, degree of inflammation, specific ocular symptoms, and presence of any aesthetic changes. Establishing this base of information then leads to determination of the appropriate treatment, Lelli said.

Treatment ranges from addressing symptoms with dry eye drops, for example; antioxidants to decrease the inflammation; oral or intravenous anti-inflammatories; and surgery to relieve ocular bulging, eyelid retraction, and diplopia. “There is a wide range of treatment options, but they hinge on assembling the right team of clinicians who can properly diagnose and categorize patients,” he said.

Although there currently is no cure for TED, Lelli reported that more targeted treatments for patients are in the offing.

“A lot of the disease and orbital inflammation occur at the level of the orbital fibroblasts, receptors that are targeted by the autoimmune process to create inflammation,” he said. “We have ways to target those, and more research is being done. We can make the disease substantially more tolerable for patients.”

TED awareness

The second TED awareness week was held this year, with a focus of disseminating more information about TED to patients and clinicians alike. A small percentage of patients with TED (ie, 5%-10%) have hypothyroidism, and a baseline examination is warranted.

The goal is to provide information to patients, ophthalmologists, and other eye care clinicians to raise their awareness of TED signs and symptoms in patients who have a history of thyroid disease, according to Lelli. A referral to an oculoplastic surgeon or neuro-ophthalmologist may catch the disease early in the process.

Lelli advises that clinicians who have patients with Graves disease or a thyroid condition should look for the signs and symptoms of TED. If a clinician is suspicious that a patient may have TED, speed is of the essence. An early evaluation by specialists can help get the patients on the right treatment path if warranted. Lelli also suggested the website, focusonted.com, to provide useful information about the disease for patients and doctors as well as specialists listed by ZIP code.

Gary Lelli, MD

E: gjl9003@med.cornell.edu

Lelli has no proprietary interest in any aspect of this report.