Graves’ Ophthalmopathy: VISA versus EUGOGO Classification, Assessment, and Management

Table 6

Orientative therapeutic protocol for Graves’ ophthalmopathy (see text for bibliographic references).

All patients	Restore euthyroidism
	Avoid smoking
	Conservative local measures
Severity	Activity
	Active	Nonactive
Mild	(i) Artificial tears; (ii) Sunglasses; (iii) Head of the bed slightly elevated; (iv) Selenium (200 /g daily × 6 months); (v) Fresnel-type prisms; (vi) Botulinum toxin in Müller muscle	(i) Artificial tears; (ii) Prisms; (iii) Botulinum toxin in Müller muscle; (iv) Surgical Müllerectomy; (v) Blepharoplasty
Moderate-severe	(i) Intravenous methylprednisolone: 1st, 500 mg/week × 6 weeks; 2nd, 250 mg/week × 6 weeks; 3rd, if activity persists: consider prolongation of treatment up to 8 g of maximum cumulative dosage; 4th If non responsive after 6 weeks, change the treatment; (ii) Patients resistant to glucocorticoids: (a) Association of cyclosporin A (5 mg/kg/day in 2 doses) plus oral glucocorticoids, methotrexate (7,5–10 mg/week), tocilizumab (8 mg/kg/every 4 weeks), and Rituximab (500 mg–1000 mg),; (b) If muscular involvement predominates: orbital radiotherapy (20 Gy) (not in <35 years or diabetic patients); (iii) Consider botulinum toxin in extraocular muscles if with diplopia (medial rectus or inferior rectus)	1st, orbital decompression (2 or 3 walls depending on the degree of exophthalmos); 2nd, surgery for strabismus (stability of 6-month deviation angle. Muscular recessions); 3rd, palpebral surgery; (i) Palpebral retraction: levator recession surgery, retractors for the lower eyelid.; (ii) Blepharoplasty of upper eyelids, lower eyelids, or both.
Threat to vision
Dysthyroid optic neuropathy	Methylprednisolone 1 g intravenously × 3 days, repeat after a week; If nonresponsive: urgent orbital decompression. (+/− glucocorticoids intravenously if still active +/− radiotherapy)	Urgent deep orbital medial wall decompression
Severe exposure keratopathy	Intravenous methylprednisolone when relevant orbital inflammation; palpebral closure, lubrication, tarsorrhaphy, botulinum toxin in Müller muscle, and orbital decompression if other measures are inefficient	Lateral tarsorrhaphy, orbital decompression, amniotic membrane transplant, and corneal transplant