1. Aetna considers orbital decompression surgery, eye muscle surgery and/or eyelid surgery medically necessary for members with severe Graves' ophthalmopathy (especially individuals with marked proptosis and optic neuropathy) when both of the following measures have not been successful:

   1. A trial of conservative measures, such as elevating the head at night, cool compresses, sunglasses, lubricating eyedrops, and if the member has strabismus, prisms for glasses; and

   2. A trial of medications, such as diuretics, prednisone, methimazole, and propylthiouracil.

      Note: According to available literature, surgical treatment should not be undertaken until stability of the thyroid-related orbitopathy (TRO) has been demonstrated. One of the advantages of waiting for stability of TRO is that some cosmetic problems may resolve or improve without intervention. Fat pad removal is commonly requested with surgery for exophthalmos and is generally cosmetic in nature, and therefore, is considered not medically necessary.

2. Aetna considers the use of banked human tissue graft (e.g, Alloderm) to elevate the lower eyelids in members with lower eyelid retraction associated with Graves ophthalmopathy experimental and investigational because there is insufficient evidence to support this approach.

Graves' disease (also known as Parry's or Basedow's disease) is a complex disease whose pathogenesis is believed to be autoimmune. It is a disorder that affects mainly females, and although it may occur at any age, has a peak incidence in the 3rd and 4th decades. Graves' disease has three principal manifestations: (i) hyperthyroidism with diffuse goiter, (ii) ophthalmopathy, and (iii) dermopathy; however, they do not necessarily appear simultaneously.

Graves' ophthalmopathy, also known as thyroid-associated ophthalmopathy (TAO), occurs in 2 - 7% of patients with Graves' disease with the major manifestations being proptosis, ophthalmoplegia, optic neuropathy, and/or eyelid retraction. TAO is the commonest cause of proptosis in adults. The term exophthalmos is used exclusively to describe the proptosis of TAO; exophthalmos may be unilateral early but usually becomes bilateral with time. The term exophthalmic ophthalmoplegia refers to the ocular muscle weakness that results in impaired upward gaze and convergence and strabismus with varying degree of diplopia.

Physicians recommend treatment of Graves' ophthalmopathy according to each patient's symptoms. Sometimes combinations of the following procedures are used:

• Elevating the head at night, cool compresses, sunglasses, lubricating eyedrops, or prisms for glasses;
• Medications or radiation to shrink tissue;
• Orbital decompression surgery;
• Eye muscle surgery, eyelid surgery, or both.

An assessment by the National Institute for Health and Clinical Excellence (2005) found that retrobulbar irradiation to be an effective procedure in patients for whom other treatments are inadequate or are associated with significant side effects.

Orbital Decompression Surgery

In orbital decompression surgery, the bone between the orbit and the sinuses is removed. A successful procedure improves vision and provides room for the eye to slip back into the orbit's protection. Orbital decompression is indicated in patients with severe ophthalmopathy refractory to medications and radiotherapy, especially in the presence of marked proptosis and optic neuropathy.

Eye Muscle Surgery

Diplopia often occurs because the eyes are misaligned. Usually, misalignment is caused by one or more eye muscles that are too short or “tight” due to scar tissue from Graves' ophthalmopathy. This scar tissue results from changes surrounding the eye because of swelling. The goal of eye muscle surgery is to attain single vision when looking straight ahead and looking down when reading. During eye muscle surgery, the muscle is cut from its attachment to the eyeball and re-attached further back on the eye. Usually eye muscle surgery does not require an overnight stay in the hospital. The physician evaluates the final results about 2 months later. More than one operation is sometimes required.

If orbital decompression and eye muscle surgery are to be performed, the orbital decompression surgery generally is carried out first.

Eyelid Surgery

Graves' ophthalmopathy generally causes the eyelids to open more widely. The front surface of the eyeball becomes exposed beyond the eyelid and causes excessive tearing and discomfort. Lid retraction may be improved by orbital decompression, especially the lower lid. However, the backward and downward movement of the globe following decompression may accentuate upper lid retraction. Surgical re-positioning (recession) of the upper lid retractors may have to be performed as an adjunct.

If orbital decompression, eye muscle, and eyelid surgery are required, the eyelid procedure is generally performed as the final operation in a series.

Acellular human dermis is being investigated for elevating the lower eyelids in lower eyelid retraction associated with Graves ophthalmopathy. However, current evidence in the peer reviewed medical literature is limited to case reports and small, retrospective case series.

Orbital Radiation

Zoumalan and colleagues (2007) noted that thyroid eye disease (TED, Graves' ophthalmopathy, thyroid ophthalmopathy) is the most common cause of orbital inflammation and proptosis in adults. There is no agreement on its management although corticosteroids and external beam orbital radiation have traditionally been believed to provide benefit in active inflammation. A review of the published literature in English disclosed an overall corticosteroid-mediated treatment response of 66.9 % in a total of 834 treated patients who had moderate or severe TED. Intravenous corticosteroids used in repeated weekly pulses were more effective (overall favorable response = 74.6 %, n = 177) and had fewer side effects than daily oral corticosteroids (overall favorable response = 55.5 %, n = 265). A combination of corticosteroid and radiation therapy seemed to be more effective than corticosteroids alone. However, the authors stated that these conclusions are tempered by a notable lack of standardization within and between study designs, treatment protocols, and outcome measures. Accordingly, the North American Neuro-Ophthalmology Society, American Society of Ophthalmic Plastic and Reconstructive Surgery and the Orbital Society, in conjunction with Neuro-Ophthalmology Research and Development Consortium, will investigate the design and funding of a multi-center controlled trial.

A technology assessment on orbital radiation for Graves ophthalmopathy by the American Academy of Ophthalmology (Bradley et al, 2008) examined if orbital radiation offers effective and safe treatment for Graves ophthalmopathy. Medical literature databases were searched to identify all published reports relating to orbital radiation treatment for Graves ophthalmopathy. To be included in the technology assessment, reports had to provide original data, to report on a case series or uncontrolled trial of at least 100 subjects or a randomized clinical trial (RCT) of any size, to focus on orbital radiation for the treatment of Graves ophthalmopathy, and to follow-up patients for at least 3 months. Abstracted data included study characteristics, patient characteristics, treatment response, and safety information. A total of 14 studies were included in the technology assessment: 5 observational studies and 9 RCTs. Three of the observational studies reported on treatment response, with overall favorable outcomes for 40 % to 97 % of patients. Three of the observational studies provided intermediate-term safety data. The risk of definite radiation retinopathy is 1 % to 2 % within 10 years after treatment. Patients treated with orbital radiation did not have an increased risk of secondary malignancy or premature death. The 9 RCTs were qualitatively heterogeneous. Patients with optic neuropathy generally were excluded from participating in the RCTs. Three of the RCTs were sham-controlled. None of these studies showed that orbital radiation was more effective than sham irradiation for improving proptosis, lid fissure, or soft tissue changes such as eyelid swelling. Two of the 3 sham-controlled RCTs demonstrated improved vertical range of motion in radiation-treated subjects compared with controls. The authors concluded that systematic review of the effect of orbital radiation on Graves ophthalmopathy is limited by the lack of standardization and variable quality of published reports. Extra-ocular motility impairment may improve with radiotherapy, although the evidence of a treatment effect is mixed in clinical trials. Future studies are needed to determine if a potentially beneficial motility effect results in improved patient function and quality of life. Level I evidence indicates that proptosis, eyelid retraction, and soft tissue changes do not improve with radiation treatment. The effectiveness of orbital radiation for compressive optic neuropathy resulting from Graves ophthalmopathy has not been investigated in clinical trials and merits further study. Radiation retinopathy, although rare, is a risk of orbital radiation, even in patients without diabetes who receive appropriate radiation dose and delivery.

Guidance on retrobulbar irradiation for thyroid eye disease from the National Institute for Health and Clincial Excellence (NICE, 2005) concluded: "Current evidence on the safety and efficacy of retrobulbar irradiation for thyroid eye disease appears adequate to support the use of this procedure in patients for whom other treatments are inadequate or associated with significant side effects."