August 05, 2025
3 min read
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Two scenarios to consider surgery
Surgery is considered in either of the two following situations:
- When there is active disease that is vision threatening and not responding to nonsurgical treatment.
- When there is quiescent disease, meaning no erythema or edema, and exam stability for about 6 months.
The first thing to keep in mind when thinking about thyroid eye disease is that there has been no randomized controlled trial to establish one specific algorithm for treatment. There are many factors to consider when it comes to medical vs. surgical management, and each of the different methods has risks and benefits.
Let’s discuss the first question many patients and ophthalmologists ask: What is the role of Tepezza (teprotumumab-trbw, Amgen)? More evidence is emerging that rates of recurrence after treatment are much higher than anticipated, up to 60% to 70% depending on the study. Then, you factor in the drug’s side effects profile of permanent hearing loss, elevated blood sugars, muscle cramping and birth defects. With the risks and drug costs of about $300,000 per patient, that is a lot to go through for the patient, doctor and payer for it not to work.
In addition to teprotumumab, there are other nonsurgical options that can be considered, such as IV steroids, low-dose radiation, and even periocular injections of steroids or botulinum toxin. While these medical therapies are part of the treatment paradigm, surgery definitely plays a part — typically once the patient’s exam seems stable.
Thyroid eye disease has an active phase and a quiescent phase. There is some debate about this as well, but most people believe there is an active period of about 1 to 5 years in which the eye socket is actively changing. That means swelling and changing eyelid retraction, strabismus and proptosis. This is not a good time to do surgery because it would be surgery on a moving target.
The exception to that rule would be if the patient is losing vision or otherwise in danger of having damage to the eye. In those cases, we would do surgery to protect the eye until things calm down.
Thyroid eye disease involves three main categories of surgery, which can be crucial to help patients regain their ability to function in daily life. One is decompression, which addresses proptosis. If needed, the next surgery to be considered is strabismus surgery, which is usually done by a pediatric ophthalmologist. Lastly, there is retraction repair, which allows lids to be more even, allows the eye to close better and decreases dry eye symptoms.
This can be a challenging process for patients to go through. Patients typically appreciate hearing that acknowledgement and hearing that you will be there for them or refer them to the right physician.
For more information:
Anne Barmettler, MD, director of ophthalmic plastic and reconstructive surgery at Montefiore Einstein, can be reached at abarmett@montefiore.org.
Depends on the patient and disease severity
There is no question that the explosion of interest in thyroid eye disease has been tied to the development of Tepezza (teprotumumab-trbw, Amgen). Its approval in 2020 revolutionized a lot of our thoughts about thyroid eye disease.
Traditionally, we always thought that when the muscles became large, they became permanently scarred and restricted, with nothing to change that. Teprotumumab has taught us that a lot of our strongly held beliefs about thyroid eye disease may actually be wrong. The muscles can change in size, their function can change, and medical therapy can be used in a number of ways. However, it cannot fix all problems.
Some patients present with acute dysthyroid optic neuropathy and may need emergent surgery. That surgery needs to be performed before you are going to see a change affected by teprotumumab.
Surgery will never go away with thyroid eye disease because while many of the inflammatory signs can be improved or ameliorated with medical therapy, it does not eradicate mechanical changes. That means medical and surgical treatment will continue to go hand in hand but in a much better way.
We used to have this concept that we would let the disease “burn itself out.” However, many patients have a chronic inflammatory condition, and it will never completely burn itself out. It could even exacerbate or flare just like any other autoimmune disease. Moving forward, we will see more long-term treatment of patients with thyroid eye disease. They might take one drug that acutely reverses inflammatory changes and another that can keep those improvements in place.
It is true that some patients may not need orbital decompression after medical therapy, but many patients want to achieve optimal restoration of their form and function. Surgery is necessary to achieve that objective. We might be doing surgery less often and less invasively, but surgery will still be needed.
In the mechanical domain of thyroid eye disease, the best intervention is likely surgical. If someone has a retracted eyelid that stays persistently retracted despite normalized thyroid function, that patient is likely going to need correction of their upper eyelid. For all those patients with mechanical issues that we treat, surgery is still going to be a critical part of the equation.
For more information:
Louise A. Mawn, MD, professor of ophthalmology and neurological surgery at Vanderbilt University Medical Center, can be reached at louise.a.mawn@vumc.org.
Sources/Disclosures
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Disclosures:
Barmettler reports no relevant financial disclosures. Mawn reports serving as an advisor and consultant for Amgen and Genentech and doing research work for Genentech.
