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n/a
Document type
Clinical policy
Place
Hertfordshire and West Essex ICB
Output type
Clinical Policies & Evidence-based Interventions
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Dysthyroid Eye Disease

July 2022 v1.0

This policy has been produced on behalf of local ICBs and covers ICB funding of thyroid eye disease, clarifying the responsibilities of ICBs and NHSE in the commissioning and funding of thyroid eye disease. The guidance does not cover NHSE funding but clarifies where their responsibilities lie. 

Treatment of thyroid eye disease (TED) is only funded by ICB’s in cases of mild disease (see classification below). For moderate or severe disease NHS England is the responsible commissioner. The treatment of mild disease is primarily medical, not surgical; therefore, it is not anticipated that any surgery for thyroid eye disease would be routinely funded by local ICB’s.

Spectacle lenses including specialist lenses are also an NHS England responsibility. 

Funding criteria:

Any requests for ICB funding of surgery would be exceptional and would only be considered as an individual funding request (IFR). See appendix A for OPCS codes.

The ICB funding responsibilities are for mild disease, with NHSE the commissioner for moderate or severe disease. Disease severity is assessed using the EUGOGO criteria, shown below.(1) 

Sign/symptom

Mild disease

Moderate/severe disease

Lid retraction

<2 mm

≥2 mm

Soft tissue involvement

Mild

Moderate or severe

Exophthalmos

<3 mm

≥3 mm

Diplopia

None or transienta

Inconstantb or constantc

Corneal involvement*

None or mild

Moderate or severe

a Transient diplopia: in primary position when tired or first awakening

b Inconstant diplopia: at extremes of gaze

c Constant diplopia: continuous in primary position or when reading

*Punctate keratopathy responsive to topical lubricants within 1 week would be classified mild. All other corneal involvement e.g., non-responsive punctate keratopathy, ulcer or perforation is considered moderate/severe.

Clinical management:

Management appropriate for mild disease:

Management of mild disease is mostly self-management optimisation of the patient’s thyroid status, e.g.: 

  • Smoking cessation 
  • Correction of thyroid function
  • Artificial tears (obtained over the counter from community pharmacies) 
  • Prism lenses (NHSE responsibility) 
  • Self-help groups

Management appropriate for moderate to severe disease – (NB NHS England is responsible for commissioning)

  • IV steroids
  • Orbital irradiation
  • Orbital decompression
  • Muscle surgery
  • Eyelid surgery

References

  1. Bartalena L, Baldeschi L, Dickinson A, Eckstein A, Kendall-Taylor P, Marcocci C, et al. Consensus statement of the European Group on Graves’ orbitopathy (EUGOGO) on management of GO. Eur J Endocrinol. 2008 Mar 1;158(3):273–85. 


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