Introduction: Treatment of Graves' orbitopathy (GO) is a difficult challenge and should be performed through a multidisciplinary approach.
Areas covered: This review covers the current treatment of hyperthyroidism and its effect on the course of GO. Treatment options for GO, according to its severity and activity, are discussed.
Expert opinion: In hyperthyroid patients, euthyroidism should be restored with antithyroid drug (ATD) therapy. High-dose i.v. glucocorticoids (ivGC) should be immediately given to patients with optic neuropathy, and orbital decompression should be performed in non-responders. Permanent treatment of hyperthyroidism (by radioiodine or surgery) should be planned in patients with moderate-to-severe and active GO, followed by a course of ivGC associated with orbital radiotherapy, particularly when eye muscle involvement is present. Patients should be carefully evaluated for liver, cardio- and cerebrovascular risk factors. Rehabilitative surgery (orbital decompression, squint and eyelid surgery) should be considered when GO is inactive, or to improve the results of medical therapy. In patients with mild GO long-term ATD therapy and a 6-month course of selenium should be used. Ablative therapy should be considered in patients with poorly controlled hyperthyroidism or persistently elevated thyroid-stimulating hormone (TSH) receptor antibody levels. Oral GC should be given to patients with risk factors or active GO, if radioiodine is used.