ate preoperative period(10 days)to decrease thyroid vascularity and intraoperative blood loss [113].However. Trement of hyprhyoddein the pene Degree of severity and activity of GO ATD RAI Tx tomy must be performed be in add ade r6 and Mild and inactive SKI ed be Moderate-tovrand Yes ce the risk of RAI,radio recommendations 24 If surgery is selected,total thyroidectomy is the proce entation for 6 month dure of ch by a skilled eroid prophylaxis warranted (see text) dism should be restored by ATDprior to avoid Mild and inactive Treatment for by rthyroidism is unlikely to cause od 26 Vitamin d deficiency should be corrected to reduce ular changes and.therefore.is chosen irrespective of GO the postoperative risk of hypocalcemia.1, [116,117].If RAI treatment is selected,steroid prophy- 27 A solution containing potassium iodide can be given laxis is not indicated unless other risk factors for GOpro for 10 days prior to surgery.2,00C gression exist [115].Rehabilitative surgery may be re- quired for cosmetic or functional reasons Mild and Ac ve GO of GO and relies established criteria 2].There is no Thyroid dysfunction.both hy RCT evidence that the long-term outcome of go of thi degree is better using atd than definitive treatment ETA/EUGOGO guideline[115]and an Italian consensus Steroid prophvlaxis is indicated if RAI treatment is em statement [116]recommended that prompt restoration ployed [130].If ATD treatment is chos enium supplementation chall and prevents its progression to more severe forms [132 Thetate-to-5e Moder vere and Inactive GO might be beneficial for GO indirectly. id tr the restoration of euthyroidism [118,119].Hypothyroid. of GO.If RAI is selected,steroid prophylaxis can be ism can also cause the progression of GO 1201.RAI avoided if other risk factors for go reactivation are ab causes the progression or de novo occurrence ofGO[119, sent [1171. 121,122],particularly in smokers [123],those with pre existing]and recent-onset GO 24],lat m12 ated GO and tanc fheomiismnhATD sm are,per se 151T 1211 and two taanalyses 129,1301.Steroid p 133l.P mpt therapy for GO is warranted. laxis can be avoided in patients with absent or inactive GOifother risk factors for RAI-associated progression of Sight-Threatening go GO are absent 115.130.Thvroide my doe s not seem Sight-threatening GO is an endocrine emergency be to impact the natural history of GO 122,131 (Table 5). cause of the risk of sight loss due to dysthyroid optic neu 6 Kahaly/Bartalena/Hegeduis/Leenhardt/ Poppe/Pearce 医通 http://guide.medlive.cn/ Kahaly/Bartalena/Hegedüs/Leenhardt/ Poppe/Pearce 176 Eur Thyroid J 2018;7:167–186 DOI: 10.1159/000490384 ate preoperative period (10 days) to decrease thyroid vascularity and intraoperative blood loss [113]. However, this preparation is used by less than 40% of thyroidolo￾gists [22]. When thyroidectomy must be performed be￾fore an adequate control of hyperthyroidism is achieved, in addition to ATD, beta-blockers, glucocorticoids, and eventually SSKI may be helpful. Vitamin D deficiency should be corrected prior to surgery to reduce the risk of postoperative hypocalcemia [114]. Recommendations 24 If surgery is selected, total thyroidectomy is the proce￾dure of choice, and should be performed by a skilled surgeon with high annual volumes of thyroidectomies. 1, ∅∅∅∅ 25 Euthyroidism should be restored by ATD prior to sur￾gery to avoid peri- or postoperative exacerbation of thyrotoxicosis. 1, ∅∅∅∅ 26 Vitamin D deficiency should be corrected to reduce the postoperative risk of hypocalcemia. 1, ∅∅∅∅ 27 A solution containing potassium iodide can be given for 10 days prior to surgery. 2, ∅∅∅○ Treatment of Graves’ Hyperthyroidism in Patients with Orbitopathy Thyroid dysfunction, both hyper- and hypothyroid￾ism, can influence the course of GO. Accordingly, the ETA/EUGOGO guideline [115] and an Italian consensus statement [116] recommended that prompt restoration and stable maintenance of euthyroidism are priorities in patients with GO. How to manage hyperthyroidism when GO is present is, however, a challenging dilemma [117]. ATD per se do not influence the natural course of GO, but might be beneficial for GO indirectly, as a consequence of the restoration of euthyroidism [118, 119]. Hypothyroid￾ism can also cause the progression of GO [120]. RAI causes the progression or de novo occurrence of GO [119, 121, 122], particularly in smokers [123], those with pre￾existing [119] and recent-onset GO [124], late correction of post-RAI hypothyroidism [125, 126], and high TSH-R￾Ab levels [127]. In patients at risk of RAI-associated GO occurrence or progression, oral low-dose steroid prophy￾laxis [115, 128] is effective, as shown by two RCTs [119, 121] and two meta-analyses [129, 130]. Steroid prophy￾laxis can be avoided in patients with absent or inactive GO if other risk factors for RAI-associated progression of GO are absent [115, 130]. Thyroidectomy does not seem to impact the natural history of GO [122, 131] (Table 5). Mild and Inactive Treatment for hyperthyroidism is unlikely to cause oc￾ular changes and, therefore, is chosen irrespective of GO [116, 117]. If RAI treatment is selected, steroid prophy￾laxis is not indicated unless other risk factors for GO pro￾gression exist [115]. Rehabilitative surgery may be re￾quired for cosmetic or functional reasons. Mild and Active GO Treatment of hyperthyroidism is mostly independent of GO and relies on established criteria [2]. There is no RCT evidence that the long-term outcome of GO of this degree is better using ATD than definitive treatment. Steroid prophylaxis is indicated if RAI treatment is em￾ployed [130]. If ATD treatment is chosen, a 6-month se￾lenium supplementation improves mild and active GO and prevents its progression to more severe forms [132]. Moderate-to-Severe and Inactive GO The choice of thyroid treatment is mostly independent of GO. If RAI is selected, steroid prophylaxis can be avoided if other risk factors for GO reactivation are ab￾sent [117]. Moderate-to-Severe and Active GO Rapid correction of hyperthyroidism with ATD and stable maintenance of euthyroidism are, per se, beneficial for GO and therefore strongly recommended [60, 61, 115]. Thyroid ablation has been alternatively advocated [133]. Prompt therapy for GO is warranted. Sight-Threatening GO Sight-threatening GO is an endocrine emergency be￾cause of the risk of sight loss due to dysthyroid optic neu￾Table 5. Treatment of hyperthyroidism due to GD in the presence of GO Degree of severity and activity of GO ATD RAI Tx Mild and inactive Yes Yes1 Yes Mild and active Yes2 Yes3 Yes Moderate-to-severe and inactive Yes Yes1 Yes Moderate-to-severe and active Yes No No Sight threatening Yes No No ATD, antithyroid drugs; RAI, radioactive iodine; Tx, total thyroidectomy; GD, Graves’ disease; GO, Graves’ orbitopathy. 1  Steroid prophylaxis in selected cases. 2  Selenium supplementation for 6 months. 3  Steroid prophylaxis warranted (see text). http://guide.medlive.cn/