Management and presentation of pediatric thyroid eye disease: A systematic review and meta-analysis

BackgroundPediatric Thyroid Eye Disease (TED) is a rare autoimmune condition primarily associated with Graves' disease. Although usually milder than adult TED, it can still cause functional and psychological morbidity. Pediatric management remains unclear due to the absence of specific guidelines and concerns about treatment-related risks such as growth suppression.MethodsWe conducted a systematic review and meta-analysis following PRISMA guidelines, searching MEDLINE, Embase, and Emcare from inception to March 2024. Studies included interventional and observational reports involving patients ≤18 years with TED. Data were synthesized narratively and quantitatively. Meta-analyses were conducted using random-effects models, with heterogeneity assessed via I² statistics and meta-regression. Primary outcomes included visual acuity (VA), proptosis, Clinical Activity Score (CAS), and adverse events.ResultsThirty-two studies comprising 810 pediatric patients (mean age 11.7 years, 64.8% female) were included. The most common symptoms were exophthalmos (99.5%), eyelid retraction (73.1%), and dry eye (66.3%). Treatments ranged from antithyroid drugs and corticosteroids, to orbital decompression and biologics. Meta-analysis showed mean exophthalmos reductions of 4.69 mm for decompression, 4.25 mm for steroids, and 1.75 mm for biologics. Substantial heterogeneity and low certainty of evidence limited interpretability. Interventions were performed earlier than recommended, with no significant adverse effects reported.ConclusionsDespite most pediatric TED cases being mild, a subset of patients requires more intensive management. This review, comprising predominantly of case reports and case series with very low certainty evidence, reveals gaps between practice and recommendations, highlighting the need for pediatric-specific guidelines informed by systematic evidence.