Thyroid Eye Disease



Clinical Activity Score

Score 1 for each of the following:

  1. Spontaneous retrobulbar pain
  2. Pain on attempted up- or downgaze
  3. Redness of eyelids
  4. Redness of conjuctiva
  5. Swelling of eyelids
  6. Inflammation of caruncle or plica
  7. 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
  • Papilloedema


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
    • exophthalmos>=3mm
    • 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
    • exophthalmos<3mm
    • 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.