Thyroid eye disease- an update

Introduction: Thyroid eye disease or Graves' orbitopathy (GO) is an autoimmune condition most common in people with hyperthyroid Graves' disease. Severe GO may cause blindness and all patients have reduced quality of life and effective treatments are lacking. This has driven efforts to identify novel therapeutic options resulting in progress in our understanding of the tissue remodeling processes underpinning GO. Areas covered: We have described clinical aspects including signs and symptoms, risk factors and current treatments. We have summarized GO pathogenesis including target autoantigens, regulation of tissue remodeling and tolerance mechanisms. Finally we reflect on the possible role of the microbiome in autoimmunity. References cited were selected from pubmed using the search terms 'Graves' orbitopathy' 'thyroid eye disease.' Expert commentary: Currently the results of two clinical trials, using completely novel treatments for thyroid eye disease (TED)/GO, are awaited. The trials are the result of progress made in understanding some aspects of the pathogenesis of TED/GO (end stages of disease) mainly derived using in vitro models. However, we remain largely ignorant of the triggers that initiate and maintain the autoimmune response; studies using in vivo models are likely to shed light on the mechanisms leading to loss of tolerance.