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.