Table 6.
Orientative therapeutic protocol for Graves' ophthalmopathy (see text for bibliographic references).
| All patients | Restore euthyroidism | |
|---|---|---|
| Avoid smoking | ||
| Conservative local measures | ||
| Severity | Activity | |
| Active | Nonactive | |
| Mild | (i) Artificial tears (ii) Sunglasses (iii) Head of the bed slightly elevated (iv) Selenium (200 μ/g daily × 6 months) (v) Fresnel-type prisms (vi) Botulinum toxin in Müller muscle |
(i) Artificial tears (ii) Prisms (iii) Botulinum toxin in Müller muscle (iv) Surgical Müllerectomy (v) Blepharoplasty |
|
| ||
| Moderate-severe | (i) Intravenous methylprednisolone: 1st, 500 mg/week × 6 weeks 2nd, 250 mg/week × 6 weeks 3rd, if activity persists: consider prolongation of treatment up to 8 g of maximum cumulative dosage 4th If non responsive after 6 weeks, change the treatment (ii) Patients resistant to glucocorticoids: (a) Association of cyclosporin A (5 mg/kg/day in 2 doses) plus oral glucocorticoids, methotrexate (7,5–10 mg/week), tocilizumab (8 mg/kg/every 4 weeks), and Rituximab (500 mg–1000 mg), (b) If muscular involvement predominates: orbital radiotherapy (20 Gy) (not in <35 years or diabetic patients) (iii) Consider botulinum toxin in extraocular muscles if with diplopia (medial rectus or inferior rectus) |
1st, orbital decompression (2 or 3 walls depending on the degree of exophthalmos) 2nd, surgery for strabismus (stability of 6-month deviation angle. Muscular recessions) 3rd, palpebral surgery (i) Palpebral retraction: levator recession surgery, retractors for the lower eyelid. (ii) Blepharoplasty of upper eyelids, lower eyelids, or both. |
|
| ||
| Threat to vision | ||
| Dysthyroid optic neuropathy | Methylprednisolone 1 g intravenously × 3 days, repeat after a week If nonresponsive: urgent orbital decompression. (+/− glucocorticoids intravenously if still active +/− radiotherapy) |
Urgent deep orbital medial wall decompression |
| Severe exposure keratopathy | Intravenous methylprednisolone when relevant orbital inflammation; palpebral closure, lubrication, tarsorrhaphy, botulinum toxin in Müller muscle, and orbital decompression if other measures are inefficient | Lateral tarsorrhaphy, orbital decompression, amniotic membrane transplant, and corneal transplant |