Current management of thyroid-associated ophthalmopathy in Europe. Results of an international survey

OBJECTIVE To determine how expert thyroidologists assess and treat thyroid-associated ophthalmopathy (TAO), and if TAO affects treatment of coexistent Graves' hyperthyroidism. DESIGN Members of the European Thyroid Association (ETA) were invited to answer a questionnaire which gave details of an index patient and nine variants differing in age, severity of TAO, thyroid state and the presence of diabetes. Eighty-four responses were received from 19 European countries, representing approximately 60% of the clinically active ETA members, RESULTS Disease-modifying treatment was not considered necessary by 18% for the index case with diplopia and proptosis but 77% used steroids alone or with another treatment; 5% used radiotherapy alone and 18% used it in combination with steroids. Worsening of eye signs after 8 weeks induced a significant shift away from steroids to radiotherapy, surgery, or other immunosuppression. For treatment of associated hyperthyroidism, antithyroid drugs were chosen by 84%, thyroidectomy by 10% and radioiodine by 6%, In recurrent hyperthyroidism, thyroidectomy was preferred by 43%, antithyroid drugs by 32%, and radioiodine by 25%, Major alterations in management of TAO were noted for only 2 of the 9 variants. Optic nerve involvement produced a more thorough evaluation of TAO as an in-patient, and a preference for surgical decompression (42%). The presence of diabetes induced a greater use of surgery at the expense of steroids, but there was disagreement over the role of radiotherapy in diabetes. CONCLUSION Marked geographical variation was noted, particularly in the treatment of thyroid-associated ophthalmopathy, Observed consensus was nation-wide rather than Europe-wide. The appropriate treatment of the patient with thyroid-associated ophthalmopathy, especially with diabetes or deteriorating eye signs, is controversial even amongst thyroid specialists.