Patients with significant signs or symptoms of active orbital inflammation, or with optic neuropathy or significant exposure keratopathy, should receive systemic therapy to reduce the degree of orbital inflammatory congestion. Those with an activity score of 3 or more are likely to benefit, as are those with a muscle oedema shown on STIR-sequence MRI.
Systemic steroids at high dosage (either intravenous methyl prednisolone or oral prednisolone) should be administered and the patient checked for improvement after a few days. The patient should be monitored for hyperglycaemia and hypertension during treatment and the prescription of a gastric proton-pump inhibitor or Histamine-2 receptor antagonist considered; patients on long-term steroids, especially the elderly, should be given calcium supplementation to counteract steroid-induced osteoporosis. If systemic steroids produce an improvement in the inflammatory orbitopathy, the dosage should be slowly reduced towards about 20mg daily if possible and the patient referred for low-dose, (2000-2400 cGy) lens-sparing radiotherapy to the posterior tissues of the orbit; some authors consider radiotherapy contraindicated in diabetics, as it may hasten the development of retinopathy.
Steroids probably suppress dysthyroid orbitopathy by inhibition of the production of cytokines by activated T cells and macrophages and fibroblasts within the orbit. It has been reported that treatment with steroids and radiotherapy is more effective than treatment of orbitopathy with steroids alone. As there may be an increase in orbital inflammation and oedema whilst undergoing orbital radiotherapy, it is prudent to continue a moderate steroid dosage (for example, prednisolone 20mg daily) during this treatment.
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