Corneal breakdown in thyroid eye disease: Presentation and outcomes over a decade.

Purpose: Corneal breakdown in thyroid eye disease (TED) is an ocular emergency. This study aimed to assess the outcome of multimodal management for corneal breakdown in TED.

Methods: This retrospective audit included all consecutive corneal breakdowns in TED patients between November 2011 and May 2023. The primary outcome measure was the best corrected visual acuity (BCVA), and secondary outcome measures included proptosis, clinical activity score (CAS), and proportion of globe salvage.

Results: In all, 35 TED patients (50 eyes; 15 bilateral) were included in this study. The mean age was 50.6 + 16 years (range 17-83), and 23 were male. Median TED duration was 5 months (range 1-108). Seven patients (nine eyes) developed corneal breakdown ≥2 years after disease onset. Corneal breakdown was graded as superficial punctate keratopathy in 18, microbial keratitis in 14, and microbial keratitis with thinning and/or perforation in 18 eyes. At median follow-up of 17 months (range 2-72), in the orbital decompression group, overall mean BCVA before and after orbital decompression showed improvement from 1.2 to 0.7, mean proptosis from 25.4 ± 3.5 to 20.7 ± 2.1 mm, and median CAS from 4.2 ± 1.3 to 0.3 ± 0.6. In the medical management group, the mean BCVA changed from 1.7 to 1.5, mean proptosis from 22.5 ± 2.5 to 22.3 ± 2.4 mm, and CAS from 3.0 ± 1.4 to 1.1 ± 1.4 before and after treatment, respectively. At the final follow-up, 44 eyes (88%) achieved globe salvage, while six eyes were eviscerated.

Conclusion: Corneal breakdown necessitates expeditious and intensive multimodal management - topical medications, systemic medications, eyelid surgery, and orbital decompression surgery. In severe corneal breakdown with microbial keratitis with thinning and perforation, multimodal management helps achieve a high percentage of vision and globe salvage.