TED: Orbitopathy - When to Decompress or Not

Patients with recent onset thyroid eye disease (TED) may present with rapidly progressive proptosis, periocular swelling, and ocular surface inflammatory signs. Signs and symptoms of orbital congestion may result both from the inflammatory mediators of TED (interleukins, other cytokines) and from increased turgor from water absorption/retention that comes from glycosaminoglycan deposition. In this acute phase, swelling and tissue expansion may cause eyelid retraction and lagophthalmos in addition to diplopia. Pain often occurs as well. If severe enough, swelling may cause vision-threatening corneal exposure and/or compressive optic neuropathy. Urgent orbital decompression is needed in these cases, and surgical decompression is otherwise deferred until later in the disease course.