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Graves ophthalmopathy — ABIM Board MCQ

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EasyEndocrinology/MetabolismGraves ophthalmopathyABIM Board

A 43-year-old woman with Graves disease treated with methimazole has mild bilateral proptosis and a gritty sensation in both eyes. Thyroid function tests are within the reference range. Visual acuity and color vision are normal, and she has no diplopia, corneal breakdown, or relative afferent pupillary defect. She smokes one pack of cigarettes daily. Which of the following is the most appropriate management of her eye disease at this time?

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Correct answer: B — Provide smoking-cessation treatment, ocular lubrication, and nonurgent ophthalmology follow-up

The correct answer is B. This patient has mild thyroid eye disease without diplopia, corneal injury, or optic neuropathy. Initial management includes maintaining euthyroidism, ocular lubrication for surface irritation, longitudinal eye assessment, and intensive smoking-cessation support. Smoking is the most important modifiable risk factor for progression and poorer treatment response. High-dose systemic glucocorticoids are generally reserved for active moderate-to-severe or sight-threatening disease. Orbital decompression is used urgently for compressive optic neuropathy or later as rehabilitative surgery for significant stable disease, not uncomplicated mild proptosis. Radioiodine can exacerbate thyroid eye disease, particularly in smokers, and should not be given without assessing eye risk and considering glucocorticoid prophylaxis. Omitting eye care and monitoring could delay recognition of progression.

Reference: Burch HB, et al. Management of thyroid eye disease: a Consensus Statement by the American Thyroid Association and the European Thyroid Association. Sections on local measures, smoking cessation, and referral; 2022. https://pubmed.ncbi.nlm.nih.gov/9786811/