How to manage thyroid eye disease: recent advances - a narrative review

Thyroid eye disease (TED) is a complex autoimmune disorder and the most common extrathyroidal manifestation of Graves' disease, characterized by orbital inflammation, tissue remodelling, and varying degrees of functional and cosmetic impairment. Although often mild, moderate-to-severe and sight-threatening forms can significantly compromise vision and quality of life. Advances in the understanding of TED pathophysiology - particularly the roles of orbital fibroblasts, thyrotropin receptor and insulin-like growth factor 1 receptor signalling- have transformed its diagnostic and therapeutic landscape. This manuscript provides a comprehensive and updated overview of epidemiology, risk factors, clinical presentation, diagnostic evaluation and management of TED. Current treatment strategies emphasize early risk-factor modification, restoration of euthyroidism, and a multidisciplinary approach tailored to disease activity and severity. Intravenous glucocorticoids remain the cornerstone of therapy for active moderate-to-severe disease, whereas adjunctive immunosuppressive agents and orbital radiotherapy are used in selected cases. The advent of targeted biologic therapies, particularly teprotumumab, as well as rituximab and tocilizumab, has significantly expanded therapeutic options and enabled a more personalized, phenotype-driven approach. Surgical rehabilitation continues to play a pivotal role in the inactive phase. Emerging therapies targeting novel molecular pathways hold promise for further improving patient outcomes. Despite these advances, challenges related to accessibility, cost, long-term safety and optimal patient selection persist. Ongoing research and international collaboration are expected to refine management strategies and enhance the quality of life of patients with TED.