Andrea Kossler, MD

Andrea Kossler, MD, describes her multidisciplinary co-management model with ophthalmologists and outlines a forward-looking vision for earlier diagnosis, precision medicine, and optimized surgical integration in thyroid eye disease.

Combination Strategies, Multidisciplinary Care, and the Future of TED Management

Optimal care for thyroid eye disease increasingly depends on close collaboration between endocrinologists and ophthalmic specialists. In this final segment, Andrea Kossler, MD, explains how she structures multidisciplinary care in her practice. Patients are often referred by community providers with an interest in TED; she conducts a thorough systemic workup, ensuring that thyroid status is stable and that secondary contributing factors such as diabetes or other autoimmune conditions are addressed. Imaging is obtained selectively, as TED remains primarily a clinical diagnosis.

Andrea Kossler, MD, underscores the value of parallel follow-up with both an endocrinologist and an ophthalmologist or oculoplastic surgeon. While she focuses on systemic disease control, metabolic risk factors, and access to biologic therapy, her ophthalmology colleagues monitor proptosis, optic nerve health, and other anatomic and functional parameters. This bidirectional communication helps determine whether and when patients may benefit from surgical interventions, including orbital decompression, strabismus surgery, or eyelid procedures.

Looking 3 to 5 years ahead, Dr Kossler anticipates a TED care model characterized by earlier recognition, risk-based screening, targeted induction therapy, and more selective use of surgery. She notes that patients currently may see multiple providers over 2 to 4 years before reaching a clinician equipped to manage TED comprehensively. Expanded education for both clinicians and patients, combined with greater access to biologic agents and potential combination strategies, could shorten this journey. Although she expects that oculoplastic surgeons will remain essential given the heterogeneity of disease, she envisions operating on patients earlier in the disease course and under more favorable tissue conditions, ultimately preserving vision and quality of life for a larger proportion of patients.

Andrea Kossler, MD, outlines a multidisciplinary framework in which endocrinologists and ophthalmologists share responsibility for thyroid eye disease. Her role includes confirming the diagnosis, stabilizing thyroid function, evaluating for diabetes and other autoimmune conditions, and assessing candidacy for systemic therapies such as teprotumumab. Ophthalmology partners, particularly oculoplastic surgeons, provide detailed assessments of proptosis, eyelid position, extraocular motility, and optic nerve status, ensuring that local complications are identified and managed promptly.

Communication between disciplines is central to her model. Serial evaluations on both the endocrine and ophthalmic sides inform decisions about when to escalate medical therapy or to proceed with surgical interventions. Andrea Kossler, MD, notes that late referral remains common, with many patients navigating multiple providers over years before accessing comprehensive TED care. She advocates education and streamlined referral pathways to reduce these delays and align treatment with periods of maximal potential for disease modification.

Projecting into the near future, Dr Kossler anticipates that optimal TED care will integrate early, risk-based screening; targeted biologic induction; combination or sequential immunologic strategies; and judicious surgical intervention. She suggests that greater understanding of disease heterogeneity, supported by evolving biomarkers and imaging tools, will enable a precision medicine approach in which therapy is tailored to individual inflammatory profiles, structural changes, and relapse risks. In this envisioned paradigm, earlier and more coordinated intervention could reduce irreversible disfigurement, minimize vision loss, and improve long-term quality of life for patients with TED.

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Andrea Kossler, MD, explores the management of thyroid eye disease in special populations, emerging IGF‑1R agents and alternative targets such as interleukin 6 (IL‑6) and FcRn, and the potential role of serologic biomarkers in predicting response and relapse.

Special Populations, Emerging Targets, and Biomarkers

Managing thyroid eye disease in special populations requires careful attention to both disease activity and treatment-related risks. In this segment, Andrea Kossler, MD, discusses the complexity of caring for pregnant patients, individuals with diabetes, and those with coexistent neuropathies or autoimmune conditions. She notes that pregnancy represents a state of immunologic fluctuation in which Graves disease and TED may flare during or after gestation. Teratogenic and safety considerations preclude the use of teprotumumab in pregnancy, and patients who receive this biologic therapy must avoid conception for a prolonged period after treatment.

For patients with diabetes mellitus, Andrea Kossler, MD, stresses strict glycemic control before and during therapy, given the potential for corticosteroids and IGF‑1R inhibitors to exacerbate hyperglycemia. She also highlights the need for baseline and ongoing assessment of comorbid conditions such as inflammatory bowel disease, hearing impairment, and other autoimmune disorders, which may influence the safety profile of newer agents. Close collaboration with ophthalmology is particularly important when coexistent optic neuropathy or myopathy is suspected.

The discussion then turns to emerging therapeutic targets and biomarkers. Dr Kossler describes a pipeline that includes additional IGF‑1R–directed agents and drugs targeting IL‑6 or the neonatal Fc receptor (FcRn). She suggests that combination or sequential approaches may ultimately be necessary to fully address the heterogeneity of TED, where some patients experience durable remission after a single biologic course while others manifest persistent or relapsing disease. She also anticipates a growing role for serologic markers, such as thyrotropin receptor antibodies (TRAb), thyroid‑stimulating immunoglobulins (TSI), and potentially IGF‑1R‑related antibodies, to help stratify relapse risk and guide duration of therapy.

In special populations, Andrea Kossler, MD, emphasizes the need to align thyroid eye disease therapy with broader systemic considerations. Pregnancy is associated with dynamic changes in immune function that can precipitate flares of Graves disease and TED in the antepartum or postpartum periods. Dr Kossler notes that teprotumumab is contraindicated during pregnancy and requires an extended washout period before conception, necessitating alternative strategies and careful preconception counseling. For patients with diabetes mellitus, she prioritizes aggressive glycemic control, recognizing that both systemic corticosteroids and IGF‑1R–targeted therapy can significantly worsen hyperglycemia.

Dr Kossler also highlights the importance of screening for coexisting conditions—such as inflammatory bowel disease, preexisting hearing deficits, and other autoimmune disorders—prior to initiating biologic therapy. These comorbidities may influence both drug selection and monitoring strategies. In patients with coexistent optic neuropathy or restrictive myopathy, she advocates particularly close coordination with ophthalmology and oculoplastic surgery to balance medical therapy and potential surgical interventions.

Regarding emerging therapies, Andrea Kossler, MD, describes an expanding field that includes next-generation IGF‑1R antibodies, IL‑6 inhibitors, and FcRn blockers. She envisions scenarios in which combinations of anti-inflammatory agents and disease-modifying biologics are used sequentially or concurrently, tailored to individual phenotypes (eg, inflammation-predominant vs proptosis-predominant disease). In parallel, she foresees increased reliance on biomarkers such as TRAb, TSI, and potentially IGF‑1R–specific assays, drawing analogies to how serologic profiles are already used in Graves disease to inform timing of antithyroid drug withdrawal. These tools may ultimately enable more precise prediction of treatment response and relapse risk in TED.

Andrea Kossler, MD, reviews the current therapeutic armamentarium for moderate to severe thyroid eye disease, including corticosteroids, teprotumumab, radiotherapy, and orbital decompression surgery, and discusses how these therapies fit into contemporary practice.

Therapeutic Landscape—Steroids, Biologics, Radiotherapy, and Surgery

The treatment landscape for thyroid eye disease has changed significantly with the advent of targeted biologic therapy. In this segment, Andrea Kossler, MD, contrasts traditional temporizing measures—such as systemic corticosteroids and orbital radiotherapy—with teprotumumab, a monoclonal antibody directed against the insulin-like growth factor 1 receptor (IGF‑1R). She explains that corticosteroids, whether administered intravenously or orally at high doses, can reduce inflammatory activity but often confer only transient benefit and carry meaningful risks for patients with comorbidities such as diabetes mellitus or uncontrolled hypertension.

Andrea Kossler, MD, describes high-dose intravenous glucocorticoids as “bridge” therapy, sometimes used to stabilize patients while more definitive options are pursued. Radiotherapy remains in use within some practices, although she notes that it does not address the underlying pathophysiology and may be associated with scarring. In contrast, she characterizes teprotumumab as the first agent to modify the course of TED, citing its targeted mechanism against IGF‑1R and the superior clinical outcomes observed with biologic immunomodulation compared with older off-label immunosuppressive regimens.

Despite these advances, surgery retains an important role. Dr Kossler highlights orbital decompression for patients with sight-threatening optic nerve compression or severe, disfiguring proptosis. She notes that experienced oculoplastic surgeons can achieve excellent results, but procedural timing and sequencing relative to medical therapy must be carefully considered. Collectively, her comments underscore an evolving paradigm in which biologics, bridge therapies, and surgery are deployed in a more strategic, individualized fashion.

Andrea Kossler, MD, delineates a clear distinction between legacy therapies for thyroid eye disease and newer biologic options. Systemic corticosteroids remain widely used for short-term control of active inflammation, often via high-dose intravenous regimens. However, she underscores that their benefits are frequently temporary; disease activity can recur once steroids are tapered, and prolonged exposure is problematic in patients with diabetes mellitus, hypertension, prior radiation exposure, or other contraindications. Consequently, steroids function primarily as a bridge rather than as definitive disease-modifying therapy.

Radiotherapy occupies a more limited role in her algorithm. Although still used by some practitioners, orbital radiotherapy may induce scarring and does not directly address the immunologic drivers of TED. In contrast, teprotumumab, an IGF‑1R–targeted monoclonal antibody, represents a paradigm shift as the first approved therapy to alter disease trajectory. Dr Kossler notes that manufacturer-sponsored programs can sometimes facilitate rapid access to initial doses, and that patients receiving biologic immunomodulation typically achieve more robust and sustained improvements than with older immunosuppressive strategies.

Surgical intervention, particularly orbital decompression, remains indispensable for select patients, especially those with compressive optic neuropathy or severe proptosis. Andrea Kossler, MD, emphasizes the skill of contemporary oculoplastic surgeons but cautions that appropriate sequencing relative to medical therapy is critical. Biologic treatment may reduce inflammatory burden and optimize surgical conditions, whereas surgery itself can theoretically trigger disease flares in some cases. Her approach reflects a multidisciplinary, staged strategy that leverages steroids, biologics, radiotherapy, and surgery according to disease severity, activity, and individual risk factors.

Andrea Kossler, MD, discusses when to involve ophthalmology and how evolving use of activity and severity scores intersects with quality-of-life considerations in decisions about initiating therapy.

Referral Thresholds and Activity/Severity Scoring

Determining when to refer patients with thyroid eye disease to ophthalmology is a key component of shared care. In this segment, Andrea Kossler, MD, emphasizes that it is rarely “wrong” to involve an eye specialist and that referral thresholds should be individualized based on clinician experience and patient symptoms. For individuals with only minimal, stable complaints, she may defer immediate ophthalmology referral but instructs them to notify all eye care providers of their Graves disease diagnosis.

As symptoms progress or new signs emerge—such as lid retraction, proptosis, scleral injection, or worsening tearing—Andrea Kossler, MD, moves quickly to coordinate care with ophthalmology or oculoplastic surgery. She likens this collaborative model to the routine ophthalmic surveillance employed in diabetes, positioning TED follow-up as a similarly critical element of chronic disease management. The goal is to ensure that changes in optic nerve status, corneal integrity, or orbital anatomy are detected promptly.

Dr Kossler also reflects on her evolving use of activity scoring systems, such as the Clinical Activity Score (CAS). Earlier in her experience, she tended to reserve advanced therapies for patients with CAS of 4 or greater, in line with prior guideline thresholds. Over time, however, she has placed greater weight on the patient’s perceived disease burden and quality of life. In her current practice, a significant subjective impact may constitute an indication for treatment even in the setting of lower activity scores, underscoring a more patient-centered approach.

In this section, Andrea Kossler, MD, articulates a low threshold for ophthalmology referral in patients with thyroid eye disease, noting that co-management is generally beneficial. She acknowledges that primary care clinicians and endocrinologists may reasonably continue to monitor patients with very mild, stable symptoms, provided that patients are instructed to inform all eye care professionals of their underlying thyroid disease. This ensures that optometrists, ophthalmologists, and oculoplastic surgeons remain alert to potential TED progression.

Referral becomes imperative when patients demonstrate worsening symptoms or objective findings such as lid retraction, proptosis, conjunctival injection, or increased tearing. At that juncture, Dr Kossler typically initiates or escalates systemic therapy while coordinating a dedicated ophthalmologic evaluation. This model mirrors multidisciplinary care frameworks in other chronic conditions (eg, diabetes mellitus), in which coordinated endocrine and ophthalmologic oversight is standard of care.

With regard to activity and severity scoring, Dr Kossler describes an evolution from strict adherence to threshold-based criteria (eg, Clinical Activity Score ≥4) toward a more nuanced, quality-of-life–centered paradigm. Although activity scores remain important for standardization and trial eligibility, she now considers a high symptomatic burden and functional impairment as sufficient justification for advanced interventions, even when formal scores are modest. This shift highlights the importance of integrating patient-reported outcomes into treatment decision-making in TED.

Andrea Kossler, MD

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