Management of patients with Graves’ orbitopathy: initial assessment, management outside specialised centres and referral pathways

Abstract

Graves' orbitopathy (GO) is uncommon, but responsible for considerable morbidity. A coordinated approach between healthcare professionals is required in order to meet the needs of patients. Early diagnosis can be achieved by a simple clinical assessment. Low-cost effective interventions can be initiated by generalists, which may improve outcomes. Moderateto-severe GO should be referred to specialised centres. Recommendations for clinical diagnosis, initial management and referral pathways are highlighted.

The 2016 European Thyroid Association/European Group on Graves' Orbitopathy Guidelines for the Management of Graves' Orbitopathy

“…These trends may reflect earlier diagnosis of GO and more effective management strategies of Graves' disease by endocrinologists and ophthalmologists, and underscore the role of specialized centers for early clinical care of these patients. Referral patterns vary among countries and health care systems, and further delineation of pathways of care by national bodies may facilitate this progress [15]. On the other hand, there are still patients presenting with recurrences of inflammatory signs of GO and complications due to inadequate evaluation of clinical and imaging features of GO and inappropriate treatment strategies [16].…”

New diagnosis of hyperthyroidism in primary care

“…Various symptom severity scores may aid assessment of Graves’ orbitopathy (eg, DiaGO, CAS/EUGOGO, box 6). 89 Refer urgently to ophthalmology if sight threatening complications are suspected: corneal exposure (cornea/sclera visible with eyes closed), globe subluxation (restricted eye movements), or optic neuropathy (deterioration in visual acuity or colour discrimination).…”

Recommended management of thyroid disorders

“…1,2 The management of ophthalmopathy is beyond the scope of this article, but has been reviewed recently elsewhere. 3 In most cases of primary hypothyroidism, management should be undertaken in primary care. Specialist referral is recommended for all patients with thyrotoxicosis at initial diagnosis and is necessary for the definitive management of those patients needing radioiodine, which is the treatment of choice in most patients with toxic adenoma or multinodular goitre.…”