Risk Factors and Thyroid Eye Disease Screening
Why some individuals develop TED while others do not is not entirely known, however there are some well-recognized risk factors. The incidence of TED appears to be the same in males and females, however, when present, TED is more likely to be severe in males. Those with more severe forms of hyperthyroidism, a larger goiter, and higher level of TSH receptor antibodies are at greater risk for TED. Tobacco smoking is a well-recognized risk factor for the development of TED. In addition, patients with TED who smoke are less likely to respond to treatment. Unfortunately, treatment of hyperthyroidism with radioactive iodine also increases the risk of developing de novo TED and worsening pre-existing TED.¹˒²
How Should Providers Screen Patients at Risk?
Early symptoms of TED include photophobia, eyelid swelling, tearing, and pain in the retrobulbar region. Providers should encourage patients to report such symptoms in a timely fashion. When examining patients at risk for TED, an eye exam in the office can be very helpful to identify early signs of the disease. Inspection is typically sufficient to identify eyelid retraction and/or swelling, injection, chemosis, and edema of the caruncle. Screening for binocular diplopia can also be effectively accomplished in a non-quantitative fashion. If available, Hertel exophthalmometry is useful in establishing a baseline measurement of proptosis, to be monitored during follow-up appointments.³
What Are Best Practices to Predict and Prevent TED Progression?
It is important to routinely advise patients to call with worsening diplopia, orbital pain, or proptosis. Changes in visual acuity should be reported immediately. A diminished intensity of color perception is an early sign of optic nerve compression and should be reported immediately as well.
Some modifiable risk factors involved in the progression of TED should be addressed. Euthyroidism should be carefully maintained, as both uncontrolled hyperthyroidism or hypothyroidism may have a negative effect on the course of TED.⁴ Smoking is a risk factor for severe TED and for resistance to treatment, therefore smoking cessation efforts should be actively encouraged.⁵ When planning treatment for hyperthyroidism, the pros and cons of radioactive iodine treatment, including a risk for worsening TED should be carefully discussed with the patient. If radioactive iodine treatment is selected in patients with pre-existing TED, then protective treatment with glucocorticoids should be considered.³
Dr. Barbesino is a consultant for Horizon Therapeutics, Viridian Therapeutics, and Immunovant.
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