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Eur Thyroid J. 2016 Mar;5(1):9-26. doi: 10.1159/000443828. Epub 2016 Mar 2.

The 2016 European Thyroid Association/European Group on Graves' Orbitopathy Guidelines for the Management of Graves' Orbitopathy.

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Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, Ospedale di Circolo, Varese, Italy.
Department of Ophthalmology, Hospital Saint Luc, Catholic University of Louvain, Brussels, Belgium.
Ophthalmology Department, Aristotle University of Thessaloniki, Thessaloniki, Greece.
Zentrum für Augenheilkunde, Universitätsklinikum Essen, Essen, Germany.
Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany.
Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
Department of Endocrinology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
Graves' Orbitopathy Center, Endocrinology, Fondazione Ca' Granda IRCCS, University of Milan, Milan, Italy.
Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.


Graves' orbitopathy (GO) is the main extrathyroidal manifestation of Graves' disease, though severe forms are rare. Management of GO is often suboptimal, largely because available treatments do not target pathogenic mechanisms of the disease. Treatment should rely on a thorough assessment of the activity and severity of GO and its impact on the patient's quality of life. Local measures (artificial tears, ointments and dark glasses) and control of risk factors for progression (smoking and thyroid dysfunction) are recommended for all patients. In mild GO, a watchful strategy is usually sufficient, but a 6-month course of selenium supplementation is effective in improving mild manifestations and preventing progression to more severe forms. High-dose glucocorticoids (GCs), preferably via the intravenous route, are the first line of treatment for moderate-to-severe and active GO. The optimal cumulative dose appears to be 4.5-5 g of methylprednisolone, but higher doses (up to 8 g) can be used for more severe forms. Shared decision-making is recommended for selecting second-line treatments, including a second course of intravenous GCs, oral GCs combined with orbital radiotherapy or cyclosporine, rituximab or watchful waiting. Rehabilitative treatment (orbital decompression surgery, squint surgery or eyelid surgery) is needed in the majority of patients when GO has been conservatively managed and inactivated by immunosuppressive treatment.


Cyclosporine; Eyelid surgery; Glucocorticoids; Graves’ orbitopathy; Orbital decompression; Orbital radiotherapy; Rituximab; Selenium; Squint surgery

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