Sonalika Khachikian, MD, is an endocrinologist at Monument Health.

Sonalika Khachikian, MD

The Future of Thyroid Eye Disease Care: Early Diagnosis and Precision

Earlier diagnosis and more personalized treatment strategies are expected to define the next phase of thyroid eye disease care.

In this video, Sonalika Khachikian, MD, an endocrinologist at Monument Health Hospital in South Dakota, highlights the current diagnostic delays many patients experience before reaching a clinician experienced in TED management and emphasizes the importance of education to improve early recognition of ocular symptoms.

Broader implementation of guideline-driven screening for all patients with thyroid disease may facilitate earlier intervention, alongside aggressive modification of risk factors such as smoking and thyroid dysfunction. Khachikian anticipates that targeted biologic therapies will increasingly be used earlier in the disease course to prevent irreversible structural changes, potentially reducing the need for surgical intervention in some patients.

She concludes by envisioning a precision medicine paradigm in which clinical phenotype, biomarkers, and patient preferences guide therapy selection. Multidisciplinary collaboration and patient engagement will remain essential to achieving durable outcomes as the TED treatment landscape continues to evolve.

Videos

Earlier diagnosis and more personalized treatment strategies are expected to define the next phase of thyroid eye disease care. 


Emerging Biologic Targets and Disease Heterogeneity in TED

Rapid advances in immunology are expanding the therapeutic landscape for thyroid eye disease beyond first-in-class IGF-1 receptor inhibition.

In this video, Sonalika Khachikian, MD, an endocrinologist at Monument Health Hospital in South Dakota, anticipates the development of additional IGF-1R–directed therapies with varying molecular properties and dosing schedules, noting that increased competition may broaden treatment options and improve access.

Beyond IGF-1R, Khachikian highlights alternative inflammatory pathways under investigation, including interleukin 6 inhibition and neonatal Fc receptor blockade. Drawing parallels to rheumatologic disease management, she suggests these agents may be particularly useful in patients whose disease phenotype is dominated by inflammatory symptoms rather than structural orbital changes. Such therapies may serve as adjuncts or induction strategies, though infection risk and systemic safety will require careful consideration.

She underscores the heterogeneity of TED, observing that while many patients respond durably to biologic therapy, others experience relapse or fluctuating disease activity. These patterns remain incompletely understood and were the subject of ongoing discussion at recent scientific meetings, including the American Thyroid Association. Her comments highlight the need for continued research to refine long-term management strategies.

Adjunctive Therapies, Surgery, and Special Populations in TED

Management of thyroid eye disease (TED) may require adjunctive medical therapies and surgical intervention, particularly in patients with severe, refractory, or high-risk disease features.

In this video, Sonalika Khachikian, MD, an endocrinologist at Monument Health Hospital in South Dakota,reiterates that high-dose intravenous glucocorticoids often function as bridge therapy, providing rapid but temporary relief of inflammation. Orbital radiotherapy remains in use among some specialists but does not address the underlying disease mechanism and may contribute to scarring, limiting its role in the biologic era.

Khachikian notes that teprotumumab has reshaped this treatment landscape by offering a targeted, disease-modifying approach through IGF-1 receptor inhibition. She describes practical considerations around access and coordination for eligible patients. In contrast, older immunomodulatory agents historically used in TED were often selected due to limited alternatives and are not strongly supported by current evidence. For patients with optic nerve compression or sight-threatening disease, orbital decompression surgery remains essential, with timing guided by disease activity and multidisciplinary input.

Special populations require tailored management. In pregnancy, TED activity may fluctuate with immune changes, and teprotumumab is contraindicated, necessitating contraception for at least 6 to 12 months after treatment. In patients with diabetes mellitus, glycemic optimization is critical to reduce inflammatory burden and mitigate treatment-related hyperglycemia. Khachikian emphasizes close coordination with ophthalmology in patients with early optic neuropathy or significant orbitopathy to balance therapeutic benefit and risk.

Management of thyroid eye disease (TED) may require adjunctive medical therapies and surgical intervention, particularly in patients with severe, refractory, or high-risk disease features. 


Referral Timing and Treatment Decisions in Thyroid Eye Disease

In this video, Sonalika Khachikian, MD, an endocrinologist at Monument Health Hospital in South Dakota, stresses that it is “never wrong” to involve an ophthalmologist and that referral decisions depend on clinician experience and symptom burden. Patients with very mild, minimally symptomatic disease may initially be monitored in endocrinology with close follow-up, but she emphasizes early referral for those who exhibit progression, lid retraction, proptosis, scleral injection, increased tearing, or functional impact.

Historically, Khachikian relied on a clinical activity score (CAS) of ≥4 to select patients for advanced therapy, consistent with earlier guideline frameworks focused on inflammatory activity. Over time, however, her approach has shifted toward incorporating patient-reported quality of life as a key determinant of treatment candidacy. Once TED is confirmed clinically, she evaluates how significantly symptoms interfere with daily function and emotional well-being, noting that patients with substantial burden may warrant therapy even with lower CAS values, provided thyroid status is stable.

Regarding first-line management of moderate to severe active TED, Khachikian describes the traditional use of lubricating eye drops and systemic glucocorticoids to reduce inflammation. She highlights limitations of steroids, including contraindications in patients with uncontrolled diabetes or hypertension and the risk of symptom recurrence after tapering. These challenges have paved the way for biologic therapy, particularly teprotumumab, which she characterizes as the first treatment shown to meaningfully modify disease course rather than serve as temporary symptom control.

Khachikian emphasizes that TED and Graves hyperthyroidism are distinct but related disease processes, with the immune response directed at both the thyroid and orbital tissues. She describes her experience with euthyroid and hypothyroid TED, estimating that roughly 90% of her TED patients have hyperthyroidism, about 15% have hypothyroidism over the disease course, and fewer than 10% are euthyroid. For patients with classic ocular features and normal thyroid function, she often pursues antibody testing (eg, thyrotropin receptor antibodies) and reviews family history to uncover autoimmune thyroid disease.

Screening has been shaped by the American Thyroid Association (ATA) guideline update in November 2022, which recommends that all patients with thyroid disease be screened for TED. In her practice, Khachikian incorporates systematic questioning into every visit with a patient who has hyperthyroidism, asking about dryness, grittiness, tearing, pressure, and other nonvisual symptoms while simultaneously observing for overt changes such as lid retraction or proptosis. For patients with early or mild disease, she initiates education and supportive measures, including lubricating eye drops, elevation of the head of the bed, smoking cessation counseling, and aggressive normalization of thyroid function.

Timely referral and accurate assessment of disease activity and severity are critical determinants of outcomes in thyroid eye disease (TED) management.

Sonalika Khachikian, MD

Articles