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.