A patient with thyroid eye disease (TED) has proptosis of 26 mm, exposure keratopathy, and compressive optic neuropathy. Visual acuity has dropped from 6/6 to 6/24 over 3 weeks despite IV methylprednisolone. What is the next best step?

• A Add oral prednisolone and reassess in 4 weeks
• B Start orbital radiotherapy
• C Initiate teprotumumab (anti-IGF-1R) therapy
• D Urgently perform orbital decompression surgery ✓

Explanation

Compressive optic neuropathy in TED (DON) that fails to respond to high-dose IV corticosteroids within 2 weeks (or that deteriorates) is an indication for urgent surgical orbital decompression. Decompression reduces retrobulbar pressure on the optic nerve and is the definitive treatment for steroid-resistant DON. Radiotherapy has a delayed response (weeks to months) and is not appropriate for urgent DON. Teprotumumab reduces proptosis but is not an emergency DON treatment.

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.