Surgical or medical decompression as a first‐line treatment of optic neuropathy in Graves’ ophthalmopathy? A randomized controlled trial

<jats:title>Summary</jats:title><jats:p><jats:bold>Objective </jats:bold> Only a small percentage of Graves’ ophthalmopathy (GO) patients develop optic neuropathy with impending loss of visual acuity. Therapy with methylprednisolone pulses is the treatment of first choice in severe and active GO patients. When the effect is insufficient, patients are usually treated with surgical decompression. We investigated whether surgery could become the first‐line treatment, thus preventing treatment with steroids.</jats:p><jats:p><jats:bold>Design and subjects </jats:bold> We performed a randomized trial in 15 patients with very active GO and optic neuropathy. Six patients were treated with surgical decompression, and nine with methylprednisolone i.v. pulses for 2 weeks, followed by oral prednisone for 4 months. The primary outcome was determined by changes in visual acuity. If the eye disease deteriorated despite treatment or did not improve sufficiently, patients were switched to the other treatment arm.</jats:p><jats:p><jats:bold>Results </jats:bold> The severity and activity of GO in both groups were similar at baseline. The Clinical Activity Score (CAS) was 6·3 ± 0·8 in the surgical group <jats:italic>vs.</jats:italic> 6·0 ± 0·5 in the steroids group and the Total Eye Score was 24 ± 6 <jats:italic>vs.</jats:italic> 25 ± 6. In the surgery group, 5/6 patients (82%) did not respond because of insufficient improvement in vision (<jats:italic>n</jats:italic> = 3) or persistent chemosis (<jats:italic>n</jats:italic> = 2), and all needed further immunosuppression. In the steroids group, 4/9 patients (45%) did not improve in visual acuity (<jats:italic>P =</jats:italic> 0·132 <jats:italic>vs.</jats:italic> surgery group), and these needed decompressive surgery. All patients in whom therapy failed were switched to the other treatment arm and visual acuity improved in almost all patients. Visual acuity improved from 0·36 (0·02–0·40) to 0·90 (0·63–1·0) in the surgery group and from 0·50 (0·32–0·63) to 0·75 (0·32–1·0) in the steroids group at 52 weeks. At long‐term follow‐up in the surgery group 3/6 patients required squint surgery and 5/9 patients in the steroids group. Eyelid surgery was performed in 5/6 patients in the surgery group and in 4/9 patients in the steroids group.</jats:p><jats:p><jats:bold>Conclusion </jats:bold> Immediate surgery does not result in a better outcome and therefore methylprednisolone pulse therapy appears to be the first‐choice therapy.</jats:p>