Diagnosis and treatment progress of upper eyelid abnormalities in thyroid-eye disease

Thyroid eye disease (TED) is the most common orbital disorder among adults. Among its many clinical features, upper eyelid abnormalities-namely, retraction, lid lag, and swelling-frequently cause functional and cosmetic problems. This article reviews current knowledge on diagnosing and treating these abnormalities. We examine a range of options, from basic supportive care and local injections (botulinum toxin A, hyaluronic acid, and triamcinolone) to systemic drugs (corticosteroids, Teprotumumab, and alpha-1 antagonists) and surgery (levator recession, blepharotomy, and orbital decompression). Recent data suggest that IGF-1 receptor antagonists, especially Teprotumumab, can substantially reduce eyelid retraction and proptosis with a better safety profile than traditional glucocorticoids. Nevertheless, important questions remain: few head-to-head trials exist, the optimal timing for biologics versus surgery is unclear, and treatment needs to be individualized. Future studies should integrate artificial intelligence for quantitative eyelid assessment and promote multidisciplinary care. This review offers a practical framework for clinicians and outlines their research priorities.