Experts Discuss TED Management Strategies

Clinicians encountering patients with thyroid eye disease (TED) are often faced with challenging scenarios. At the American Academy of Ophthalmology 2020 Virtual meeting, several experts used cases to demonstrate their approaches to treating a variety of TED scenarios.

Louise Mawn, MD, of Vanderbilt Eye Institute, opened the session with a case of an 89-year-old patient who underwent surgical intervention for compressive optic neuropathy (CON). The patient had lost vision in her left eye and in the last month had stopped driving. Her color vision was decreased and she had double vision for more than a year. Her visual acuity was 20/40 and 20/80 and she had limitations in eye movement.

“I told the patient I was concerned that she had TED and recommended that we admit her,” Dr. Mawn said.

The patient’s thyroid stimulating hormone (TSH) was 0.110 mcU/mL and thyroid stimulating immunoglobin was 367. The patient said she would rather be dead than blind. Surgery was planned.

An hour into the surgery Dr. Mawn ordered a type and screen because the patient lost more blood than she typically experienced. The next day the patient was well and noted that her vision was slightly better. In the afternoon, she complained of chest pain and EKG showed mild ST segment depression. Additional labs showed decreased hemoglobin and packed cell volume. Later that day she was transfused two units of packed red blood cells.

“This case highlights to me that even the most well-performed surgeries can have extremely deleterious complications,” Dr. Mawn said. “If we had not transfused red blood cells I’m concerned this chest pain could have been life threatening.”

Her visual acuity returned to 20/25 in each eye. Color vision returned and she returned to playing bridge and normal life. Cardiology continued to follow her.

Later in the session, Suzanne K. Freitag, MD, of Massachusetts Eye and Ear and Harvard Medical School, detailed a case of TED treated with teprotumumab. The patient was a 65-year-old female with Grave’s disease diagnosed about 10 years prior. She was treated with radioactive iodine and well managed with levothyroxine. She developed eye symptoms in September 2019 and was referred to oculoplastics in January 2020. She had a history of eyelid swelling and redness, double vision in her primary gaze, and decreased vision in the left eye.

Her vision was 20/30 in the left eye and she was complaining of dimness of colors. She had upper eyelid retraction, eyelid erythema and edema, ROOF hypertrophy and severe resistance to retropulsion. She had extraocular muscle enlargement on CT images and inferior left visual field defect.

The patient required treatment and multiple options were discussed. She opted for teprotumumab, which is an intravenous infusion given every 3 weeks for 8 doses. The patient has resolution of double vision and optic neuropathy after her first dose of teprotumumab. She completed treatment and is looking better, but still had eyelid retraction.

“I am literally not recognizing my patients after treatment [with teprotumumab] is completed,” Dr. Freitag said. “Their faces are thinner. ROOF hypertrophy is resolving. This is showing us a whole new paradigm of thinking about facial changes in thyroid patients.”

A third speaker presented two cases illustrating the medical and surgical approaches to a patient with TED.

Michael Kazim, MD, of the Harkness Eye Institute – Columbia University Medical Center, presented a 66-year-old patient treated for thyroid disease with medical therapy and thyroidectomy. Despite that his TSH was 13.86 and he had TED for 5 months. Within the last 2 months, the patient noted decreased vision with visual acuity declining to 20/80 in each eye with no color vision.

He had a well confirmed diagnosis of TED and CON. His therapeutic options were a combination of steroids and radiotherapy or surgical decompression.

The patient opted for a trial of steroids, which resulted in significant improvement in his visual acuity with substantial improvement in his visual field testing.

“This put him on the radiotherapy plus steroid arm of our treatment protocol,” Dr. Kazim said.

Beyond the steroids, radiotherapy reversed active phase of the disease within 3 months coinciding with the steroid taper, shortening the disease measurably. His acuity improved to 20/25 and his field testing returned to normal.

Dr. Kazim presented a second case of a 38-year old with prior smoking history. He was being treated for Grave’s hyperthyroidism. After 8 months of active TED he started to develop left dyschromatopsia and bilateral proptosis. There was a small bit of inferior scotoma in the left eye. He was watched for 2 months and his next visit showed acuity of 20/20 and 20/30, color vision declined to zero out of six, and his left optic nerve was swollen. His field test now demonstrated significant inferior scotoma and his CT scan confirmed large extraocular muscles.

Dr. Kazim used the TED-CON formula to determine that the patient had optic neuropathy. He was treated with a 2-week trial of 100 mg prednisone with no improvement in optic nerve function. This made  him a surgical candidate. He underwent decompression. Over a period of 6 weeks, his visual acuity improved to 20/20. He recovered all color vision and his visual field test was near normal. Because his TED had been close to a year in duration by time he underwent surgery he did not require radiotherapy to shorten the disease.

“In summary, our approach to CON is a clear diagnostic, medically biased one in which steroids and radiotherapy particularly help and surgery is used when medical therapy is ineffective,” Dr. Kazim said.