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According to the American Thyroid Association, less than 1% of people with Graves' ophthalmopathy develop symptoms so severe that it leads to serious or permanent eye damage. Some researchers, however, estimate the rate may be as high as 3-5%. In its most severe form, known as dysthyroid optic neuropathy, Graves' ophthalmopathy can lead to severe visual impairment.

Graves' ophthalmopathy is considered severe if there is marked proptosis (bulging of the eyeballs), optic nerve compression, or neuropathy. If diplopia (double vision) is present in certain types of gazes (e.g. in a primary gaze looking straight ahead or when eyes are in a reading position), Graves' ophthalmopathy may also be considered as severe. The extraocular muscle (muscles that control movement of the eyeballs) are usually normal until a late stage of Graves' ophthalmopathy when they may become fibrotic (develop tough, fibrous quality) or atrophic (cells waste away).

The progression of Graves' ophthalmopathy is usually described by the active phase during which there ocular swelling and inflammation, and the inactive phase. During the inactive phase, there is no further deterioration of the eye. The active phase may last for two or more years and may be followed by partial regression of symptoms before the inactive phase begins. There are some cases, however, where Graves' ophthalmopathy can be severe even though it is in the inactive phase, due to residual symptoms that developed during the active phase.

The severity of Graves' ophthalmopathy is independent of thyroid status but is more severe when Graves' disease is not well-controlled. It often worsens for 12-18 months following the initiation of treatment for Graves' disease and then stabilizes. Approximately 60% of patients with mild Graves' ophthalmopathy improve spontaneously but prognosis is difficult to predict with certainty. Since Graves' ophthalmopathy is exacerbated by fluctuations in the levels of thyroid hormone, monitoring hormone levels is very important for stabilizing Graves' ophthalmopathy.

Mild to moderate Graves' ophthalmopathy does not require treatment even in the active phase. However, doctors recommend that patients take steps to relieve the following symptoms, thereby, preventing further damage to the eyes:

• Dryness and grittiness may be relieved by ocular lubricants or artificial tears. Some patients find that cool compresses also help.
• For patients who experience incomplete eyelid closure at night, taping the eyelids closed an effective solution. Some find that sleeping with the head elevated is also helpful.
• Light sensitivity can be eased by the use of sunglasses.
• For mild diplopia, doctors often recommend glasses with prisms.

If Graves' ophthalmopathy is severe, it is important to assess whether the patient is experiencing an active or inactive phase since patients in the active phase are more likely to respond to medical treatment and/or radiotherapy. Patients in the inactive phase are more likely to respond to surgery.

In general, treatment options for Graves' ophthalmopathy include:

• Drug therapy
• Orbital radiation therapy (ORT)
• Surgical therapy

Currently, there is no consensus regarding which treatment should be initiated first for patients with Graves' ophthalmopathy.

Drug Therapy

Drug therapy for Graves' ophthalmopathy includes: