This descriptive service evaluation aimed to characterise management of moderate-to-severe and/or sight-threatening Graves’ orbitopathy at a tertiary hospital in Western Australia, using measures derived from a local thyroid eye disease protocol aligned with 2021 EUGOGO recommendations(1).

A retrospective single-centre audit was performed of adults managed between February 2024 and February 2026 at a site without a dedicated combined thyroid eye disease clinic. Data were extracted from ophthalmology, endocrinology and immunology records. Measures included demographics, thyroid status, disease activity and severity, first-line intravenous methylprednisolone (IVMP) delivery, mycophenolate prescribing, protocol adherence, escalation therapy and adverse events.

Fifteen patients were included. Median age was 55.0 years (IQR 49.5–64.5), 8/15 (53.3%) were female and 4/15 (26.7%) current smokers. Twelve received first-line IVMP during the audit period, while three entered during second-line treatment. Among IVMP-treated patients with documented severity, 7/8 had moderate-to-severe disease and 1/8 mild disease. Baseline Clinical Activity Score was documented in 8/12, with median CAS 4 (IQR 3–6; range 3–8). Protocol adherence was 7/12 (58.3%); non-adherence reflected IVMP without mycophenolate, non-standard IVMP dosing or step-down, and incomplete IVMP courses. Mycophenolate was prescribed as planned IVMP-based combination therapy in 7 patients, most commonly by immunology (5/7), with median IVMP-to-prescription interval 39.5 days (range 0–53). Seven patients required second-line treatment, all receiving rituximab. Four subsequently received third-line tocilizumab after inadequate rituximab response, with documented response in all four. Treatment was generally well tolerated; one patient discontinued mycophenolate for gastrointestinal intolerance, with no treatment-related hospitalisations or deaths.

This audit provides an evaluation of Graves’ orbitopathy care delivered through a distributed ophthalmology, endocrinology and immunology model. It identified inconsistencies in hospital protocol adherence and opportunities to improve treatment sequencing, documentation and escalation planning. Findings will inform pathway refinement as newer treatment options become available.