Clinical Activity Score
Score 1 for each of the following:
- Spontaneous retrobulbar pain
- Pain on attempted up- or downgaze
- Redness of eyelids
- Redness of conjuctiva
- Swelling of eyelids
- Inflammation of caruncle or plica
- Conjunctival oedema
EUGOGO Urgent Referral Criteria
- Unexplained deterioration in vision
- Change in intensity or quality of colour vision
- History of eyes suddenly "popping out" (subluxation)
- Obvious corneal opacity
EUGOGO Severity Classification
- Sight-threatening GO
- dysthyroid optic neuropathy
- corneal breakdown
- Moderate-to-severe GO - not sight threatening but sufficient impact on daily life to justify the risks of immunosuppression. Will usually have one or more of the following:
- lid retraction >=2mm
- moderate or severe soft tissue involvement
- inconstant or constant diplopia
- Mild GO - insufficient impact on daily life to justify the risks of immunosuppression. Will usually have one or more of the following:
- lid retraction <2mm
- mild soft tissue involvement
- transient or nodiplopia
- corneal exposure responsive to lubricants
Steroid protocol - PAEP
IV steroid protocol
Treatment for eye disease that is both active (CAS >=3) and moderate-to-severe is IV steroids:
- 500mg IV methylprednisolone once weekly x 6 weeks;
- 250mg IV methylprednisolone once weekly x 6 weeks;
- total treatment not to exceed 8g.
IV steroids for severe disease
Accelerated steroid treatment is indicated in severe disease with manifestations of dysthyroid optic neuropathy or corneal breakdown:
- 500mg IV methylprednisolone daily x 3 days;
- then 40mg PO prednislone x 2 weeks;
- then tail off over about 4 weeks;
- if no rapid improvement then tail off prednisolone quickly: 40mg, 30mg, 20mg, 10mg, 5mg, stop on consecutive days.
When on steroids, consider:
- need to carry steroid card;
- monitor blood glucose and BP at clinic visits;
- monitor for hypokalaemia and avoid diuretics if possible;
- gastric protection e.g. omeprazole 10mg for prophylaxis or 20mg if symptomatic;
- bone protection - Adcal D3 and bisphosphonates if >5mg prednisolone for >3 months.
Steroid prophylaxis for radioiodine treatment
Patients with active GO (CAS >=3) should receive prophylactic oral prednisolone - typically 0.3-0.5mg/kg for 1 month and then tapered over further 2 months.
Patients with inactive GO (CAS <=2) and evidence of stability or improvement over preceding 2-3 months can receive radioiodine without steroid cover, so long as non-smokers and TRABs not very high.
Avoid post-treatment hypothyroidism in all cases.