Consider these clinical pearls when caring for patients affected by this condition

In North America and Europe, thyroid eye disease (TED) is the most common orbital disease and can be vision-threatening.¹ The good news: Early intervention has been shown effective at decreasing the severity of the disease.¹ In addition, early treatment in TED’s active phase can decrease the degree of permanent scarring of the orbital tissue.¹ With that said, here are clinical pearls to consider when caring for patients who may be affected by TED.

1 PUT TED ON YOUR DIAGNOSTIC RADAR

The condition can present with numerous signs and symptoms. Signs may include redness, watery eyes, and orbital inflammation from the activation of fibroblasts.² (Incidentally, this broad, nondescriptive finding of inflammation is why TED can be a challenge to diagnose.)

Symptoms may include irritation, dry eyes or pain, sensitivity to light, and blurry or double vision, caused by the orbital inflammation.

For more information on diagnosing TED, see “Understanding the TED Diagnosis” in the May 2022 issue of Optometric Management (bit.ly/OM2205TED ).

2 KNOW HOW TO MONITOR TED

Due to the number of secondary ocular consequences, such as ocular surface disease, exophthalmos, lid retraction, and more, caused by TED, there are multiple ways to monitor these patients effectively. The table above lists a few tests and respective CPT codes used for monitoring the condition. IOP check, corneal staining, and Hertel exophthalmometry do not have exact CPT codes, but are necessary in the management of TED. These tests reveal quantitative data that play a large role in monitoring for progression of the disease.

3 SINGLE OUT GRAVE’S DISEASE PATIENTS

Although Grave’s disease and TED are two separate entities, 90% of TED patients have Grave’s disease.² Therefore, it makes sense to explain to these patients, who need to be closely evaluated, the importance of a healthy lifestyle and smoking cessation, the latter of which is the major risk factor for the progression of TED.^1,3 For more information on points for education and prevention, see “A TED Talk” in the March 2022 issue of OM (bit.ly/3NxRRjl ).

4 TREAT TED’S INFLAMMATION

Teprotumumab (Tepezza, Horizon Therapeutics), which was approved by the FDA in 2020 for the treatment of adults with TED, is an intravenous infusion administered every three weeks for a total of eight infusions (24 weeks) that targets the condition’s direct inflammatory process. Specifically, it inhibits and blocks insulin-like growth factor 1 receptors, which reduce the proliferative and inflammatory process. Teprotrumumab has also been found to reverse the hypertrophy of the extraocular muscles and orbital fat.^3,4 Questions are yet to be answered on the drug, such as future costs, number of doses, rebound inflammation, etc.³

As health insurance companies’ criteria for the coverage of Tepezza can vary, it makes sense to help TED patients investigate whether they are eligible for certain cost-assistance programs, such as the Horizon Commercial Co-Pay Program, or whether they qualify for independent foundation support. (For information about assistance, visit tepezza.com/cost-and-support/ .)

5 KEEP TABS ON THE COURSE OF TREATMENT

Consider seeing the patient periodically throughout the course of the treatment to monitor their progression and side effects.³ Side effects of teprotrumumab can include muscle spasm, alopecia, diarrhea, fatigue, nausea, dry skin, headache, hearing impairment, dysgeusia, hyperglycemia, and menstrual disorders.^5,6 For more information on treatment, see “When and How to Treat TED” in the July issue of OM (bit.ly/OM2207TED ).

COMING SOON?

Several clinical trials are in process for additional treatments for TED. These emerging therapies show promise, but must demonstrate benefits, low side effects, and cost-effective alternatives to current therapeutic treatments for TED.⁷ To investigate these options, visit https://bit.ly/3KSry6x . OM

REFERENCES

1. Thyroid Eye Disease: A Summary of Information for Patients. University of Iowa Carver College of Medicine website. webeye.ophth.uiowa.edu/eyeforum/patients/thyroid-eye-disease.htm . Published September 1, 2016. Accessed July 31, 2022.
2. Bartley GB. The epidemiologic characteristics and clinical course of ophthalmopathy associated with autoimmune thyroid disease in Olmsted County, Minnesota. Trans Am Ophthalmol Soc. 1994;92:477-588. doi:10.1016/S0002-9394(14)72666-2:
3. The Bright Future of TED. Ophthalmology Times website. https://www.ophthalmologytimes.com/view/the-bright-future-of-ted . Published March 31, 2022, Accessed July 31, 2022.
4. Winn BJ, Kersten RC. Teprotumumab: Interpreting the Clinical Trials in the Context of Thyroid Eye Disease Pathogenesis and Current Therapies. Ophthalmology. 2021;128(11):1627-1651. doi:10.1016/j.ophtha.2021.04.024.
5. Tepezza: Highlights of Prescribing Information. Food & Drug Administration website. www.accessdata.fda.gov/drugsatfda_docs/label/2020/761143s000lbl.pdf . Published January 20, 2020. Accessed July 28, 2022.
6. Smith TJ, Kahaly GJ, Ezra DG, et al. Teprotumumab for thyroid-associated ophthalmopathy. N Engl J Med. 2017 376(18):1748-1761. doi:10.1056/NEJMoa1614949.
7. Dosiou C, Kossler AL. Thyroid Eye Disease: Navigating the New Treatment Landscape. J Endocr Soc. 2021;5(5):bvab034. Published 2021 Mar 17. doi:10.1210/jendso/bvab034.

Dr. Huegel graduated from the Southern College of Optometry, and is currently completing her residency in ocular disease and anterior segment at Associated Eye Care in Stillwater, Minn.