Diagnosis and assessment

Initial care and referral for specialty care

Therapy of moderate–severe TED

Therapy of sight-threatening TED

Document Overview

Design and created by Guideline Central in participation with the American Thyroid Association and European Thyroid Association.

Management of Thyroid Eye Disease

American Thyroid Association

European Thyroid Association

Publication Date: Dec 13, 2022

Page Last Updated: May 5, 2026

Activity and severity definitions for patients with thyroid eye disease

Activity
- Clinical activity score
  - The 7-item CAS is shown hereunder. Each item scores 1 point if presenta
    - Spontaneous retrobulbar pain
    - Pain on attempted up or lateral gaze
    - Redness of the eyelids
    - Redness of the conjunctiva
    - Swelling of the eyelids
    - Inflammation of the caruncle and/or plica
    - Conjunctival edema, also known as chemosis
- Active TED
  - A CAS ≥ 3/7 usually implies active TED. A history or documentation of progression of TED based on subjective or objective worsening of vision, soft tissue inflammation, motility, or proptosis is suggestive of active TED independently of the CAS
Severity
- Sight-threatening TED
  - Patients with DON and/or corneal breakdown and/or globe subluxation (Fig. 2F)
- Moderate-to-severe TED
  - Patients without sight-threatening disease whose eye disease has sufficient impact on daily life to justify the risks of medical or surgical intervention. Patients with moderate-to-severe TED usually have any one or more of the following: lid retraction ≥2 mm, moderate or severe soft tissue involvement, proptosis ≥3 mm above normal for race and sex, or diplopia (Gorman score 2–3).
Mild TED
- Patients whose features of TED have only a minor impact on daily life insufficient to justify immunosuppressive or surgical treatment. They usually have only one or more of the following: minor lid retraction (<2 mm), mild soft tissue involvement, proptosis <3 mm above normal for race and sex, transient or no diplopia, and corneal exposure responsive to lubricants.

^aA 10-item CAS is also sometimes used and includes additional points for increase of at least 2 mm in proptosis, decrease of at least 8° in any duction, and decrease of visual acuity by two lines. A limitation of the 10-item CAS is that it requires an earlier assessment of the mentioned measures, which is usually unavailable on first consultation. See Bartalena et al.

View External Image

Document Overview

Document Title: Management of Thyroid Eye Disease

Authoring Societies

American Thyroid Association

European Thyroid Association

Document Publication Date: Dec 13, 2022

Page Last Reviewed/Updated: May 5, 2026

Document Type: Consensus Statement

Country of Publication: United States

Full Text Freely Available: Yes

Full Text Guideline: www.liebertpub.com/doi/10.1089/thy.2022.0251

Source Citation: Burch HB, Perros P, Bednarczuk T, Cooper DS, Dolman PJ, Leung AM, Mombaerts I, Salvi M, Stan MN. Management of thyroid eye disease: a Consensus Statement by the American Thyroid Association and the European Thyroid Association. Eur Thyroid J. 2022 Dec 8;11(6):e220189. doi: 10.1530/ETJ-22-0189. PMID: 36479875; PMCID: PMC9727317.

Document Scope, Criteria, and Use Cases

Document Objectives: Thyroid eye disease (TED) remains challenging for clinicians to evaluate and manage. Novel therapies have recently emerged, and their specific roles are still being determined. Most patients with TED develop eye manifestations while being treated for hyperthyroidism and under the care of endocrinologists. Endocrinologists, therefore, have a key role in diagnosis, initial management, and selection of patients who require referral to specialist care. Given that the need for guidance to endocrinologists charged with meeting the needs of patients with TED transcends national borders, and to maximize an international exchange of knowledge and practices, the American Thyroid Association and European Thyroid Association joined forces to produce this Consensus Statement.

Scope: Assessment and Screening, Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D013959 - Thyroid Diseases

D006111 - Graves Disease

D049970 - Graves Ophthalmopathy

D013959 - Thyroid Diseases

D006111 - Graves Disease

D049970 - Graves Ophthalmopathy

Keywords: Graves' disease, TED, hyperthyroidism, thyroid eye disease

Target Patient Population: Nonpregnant adults (age ≥ 18 years) with TED

Target Provider Population: Endocrinologists, ophthalmologists, and other clinicians caring for adult patients with thyroid eye disease

Inclusion Criteria: Male, Female, Adult, Older Adult

Health Care Settings: Ambulatory

Intended Users: Nurse, Nurse Practitioner, Optometrist, Physician, Physician Assistant

Management of Thyroid Eye Disease

Diagnosis and assessment

Key Point 3.1

Key Point 3.2

Key Point 3.3

Key Point 4.1.1

Key Point 4.1.2

Key Point 4.2.1

Key Point 4.4.1

Key Point 4.4.2

Activity and severity definitions for patients with thyroid eye disease

Characteristics of high-risk thyroid eye disease patients

Formal ophthalmic examination for thyroid eye disease based on vision, inflammation, strabismus, appearance

Primary indications for imaging in suspected or confirmed thyroid eye disease

Initial care and referral for specialty care

Key Point 5.1.1

Key Point 5.3.1

Key Point 5.4.1

Key Point 6.1.1

Key Point 6.2.1

TED Management Algorithm

Therapy of moderate–severe TED

Key Point 7.1.1

Key Point 7.1.2

Key Point 7.1.1.1

Key Point 7.1.1.2

Key Point 7.1.1.3

Key Point 7.1.1.4

Key Point 7.1.2.1

Key Point 7.1.3.1

Key Point 7.1.4.1

Key Point 7.1.4.2

Key Point 7.1.6.1

Key Point 7.2.1

Key Point 7.2.2

Key Point 7.3.1.1

Key Point 7.3.1.2

Key Point 7.3.2.1

Key Point 7.3.3.2

Key Point 7.3.4.1

Therapy of sight-threatening TED

Key Point 8.1.1

Key Point 8.2.1

Key Point 8.3.1

Document Overview

Document Scope, Criteria, and Use Cases