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.