Approach to the patient: therapeutic mitigation of lacrimal manifestations in thyroid eye disease

CONTEXT: Thyroid eye disease (TED) is an autoimmune disease involving periocular and orbital tissue. The manifestations of TED include proptosis, diplopia, visual disturbance, and lacrimal symptoms. Dry/gritty eyes, light sensitivity, and tearing are prominent lacrimal system-related symptoms. They can be misdiagnosed as dry eye syndrome, chronic conjunctivitis, or allergies. Multiple therapeutic interventions can be utilized in the management of lacrimal symptoms of TED. EVIDENCE DESCRIPTION: Lacrimal system dysfunction occurs from immune cell infiltration of glandular tissues as well as from poor eyelid draping causing excess exposure of the globe surface. Noninvasive treatments for lacrimal system abnormalities include local supportive measures aimed at preserving eye surface tear film, systemic and topical medications such as corticosteroids which target inflammation, and biologicals which modify immune responses. Surgical interventions can mitigate the negative impact of proptosis and poor eyelid draping on corneal exposure. These procedures include orbital decompression and eyelid repair. Nonmedical interventions include smoking cessation and patient education. Multidisciplinary care can reduce misdiagnoses, improve management, and reduce the negative impact on quality of life from TED. CONCLUSION: Several treatment options are currently available to mitigate lacrimal system dysfunction in TED. More targeted therapies are emerging or have recently appeared in the clinic. Patients with mild TED can benefit from supportive care aimed at symptomatic relief. An inter-disciplinary approach to managing patients with lacrimal system abnormalities can minimize the negative impact of lacrimal insufficiency associated with TED.