for patients when Graves ophthalmopathy has been managed conservatively and inactivated by immunosuppressive treatment. IVIg is considered third line therapy if active Graves ophthalmopathy persists after treatment with glucocorticoid and other therapies, preferably in the setting of multi-disciplinary care with co-ordination between Ophthalmology, Immunology and Endocrinology. Rituximab should be considered ahead of IVIg, unless the risk of dysthyroid optic neuropathy is high, as rituximab can precipitate this complication. Diagnosis is Yes By which specialty Ophthalmologist Diagnosis must now be made by an required Ophthalmologist or Clinical immunologist as Clinical immunologist these specialities are most likely to manage patients with this rare condition. Diagnosis No By which specialty must be verified Exclusion Criteria Qualifying Severe disease where immunosuppressant treatments have failed The Specialist Working Group developed Criteria or are contraindicated these new criteria in consultation with the ESA and RANZCO. The Bartelena clinical activity score (Bartelena et al, 2016) has been Rituximab has been shown to be effective in the treatment of Graves adapted in the development of evidence Ophthalmopathy. A course of Rituximab should be considered for this items to ensure that qualifying patients have patient if not already trialled, unless contraindicated. an appropriate level of disease severity. These assessments will be used as a baseline Persistent and severe ophthalmic disease against which to compare progress at initial and continuing review to assess clinical AND
for patients when Graves ophthalmopathy has been managed conservatively and inactivated by immunosuppressive treatment. IVIg is considered third line therapy if active Graves ophthalmopathy persists after treatment with glucocorticoid and other therapies, preferably in the setting of multi-disciplinary care with co-ordination between Ophthalmology, Immunology and Endocrinology. Rituximab should be considered ahead of IVIg, unless the risk of dysthyroid optic neuropathy is high, as rituximab can precipitate this complication. Diagnosis is required Yes By which specialty Ophthalmologist Clinical immunologist Diagnosis must now be made by an Ophthalmologist or Clinical immunologist as these specialities are most likely to manage patients with this rare condition. Diagnosis must be verified No By which specialty Exclusion Criteria Qualifying Criteria Severe disease where immunosuppressant treatments have failed or are contraindicated Rituximab has been shown to be effective in the treatment of Graves Ophthalmopathy. A course of Rituximab should be considered for this patient if not already trialled, unless contraindicated. Persistent and severe ophthalmic disease AND The Specialist Working Group developed these new criteria in consultation with the ESA and RANZCO. The Bartelena clinical activity score (Bartelena et al, 2016) has been adapted in the development of evidence items to ensure that qualifying patients have an appropriate level of disease severity. These assessments will be used as a baseline against which to compare progress at initial and continuing review to assess clinical