For management of Graves' ophthalmopathy, thyroid dysfunction should be treated initially either with radioactive iodine or antithyroid medications, depending on the choice of the physician and the patient. In most cases, radioactive iodine is selected. Concomitant steroid therapy should be given only if the patient has significant Graves' ophthalmopathy. In 80% of the patients with Graves' ophthalmopathy who have minimal or mild symptoms, supportive care and observation are adequate. In mild to moderate disease, followup by an ophthalmologist, observation, and timely use of immune modulation are appropriate. For moderate and moderately severe Graves' opthalmopathy, corticosteroid therapy (40-80 mg per day for 3 to 6 months) is the first line of therapy. It is expected that 65% of patients treated in this manner will respond. Orbital radiation therapy, although widely used as an alternative, has had no measurable benefit in our recent experience. The role of radiotherapy needs to be further defined. In 3% to 5% of severe cases with optic neuropathy or severe inflammatory symptoms or proptosis, surgical decompression is needed. Patients medically treated become surgical candidates if therapy fails. After stabilization of the disease, most moderately severe and severe cases require rehabilitative surgery such as strabismus surgery or lid surgery, either alone or subsequent to orbital decompression for improvement of proptosis. The activity of the disease should be assessed. In active disease, immunosuppressive therapy is more effective. In inactive stable disease, rehabilitative surgery is often needed. Future approaches to therapy should address immunomodulation by aborting the cascade of autoimmune processes in the orbital tissue.
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