Management of Thyroid Eye Disease‑Related Strabismus

To review various treatment methods in thyroid eye disease (TED) related strabismus.

We searched in PubMed and Google Scholar and Ovid MEDLINE for keywords including TED-related strabismus, strabismus in thyroid-associated ophthalmopathy, Graves’ ophthalmopathy related strabismus or squint, and restrictive strabismus. Two expert strabismus specialists selected and evaluated the English articles that were related to our paper and had been published since 2000. Some articles were added based upon the references of the initial articles.

One hundred fifteen articles were found, 98 of which were mostly related to the topic of this review. Management of TED‑related strabismus was reviewed and categorized in non-surgical and surgical. Botulinum toxin A (BTA) is a useful non-surgical management of strabismus in an active TED and residual deviation after strabismus surgery. Postoperative under-correction is relatively more common in TED-related esotropia. Lateral rectus resection and BTA are the options to manage the problem. Muscle rectus muscle resection should be performed after maximum recession of restricted muscles. It should be avoided on a restricted or enlarged muscle. Management of TED-related vertical deviation is challenging. In these cases, the surgical treatment selected depends on forced duction test (FDT) (pre and intraoperative), orbital imaging (which muscle is enlarged), and the amount of vertical deviation (in both down-gaze and primary position).

TED‑related strabismus needs careful evaluation and management to achieve optimal outcome. Different surgical and non‑surgical options are available for intervention in TED-related strabismus.