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Several studies indeed suggest that GO occurs less frequently and that GO is less severe now than a few decades ago. In a retrospective study from the UK, the first consecutive 100 patients presenting with the diagnosis of Graves’ disease at the beginning of each decade between 1960 and 1990 were examined. The proportion of GO in these patients with Graves’ disease declined from 57% in 1960 to 35% in 1990; the proportion of patients with severe GO (diplopia, optic nerve compression) also fell from 30.4 to 20.7% [6]. A questionnaire survey among members of the European Thyroid Association, published in 1998, reports that 43% of respondents thought GO was decreasing in frequency, 42% thought it unchanged, and 12% thought it to be increasing over the last 10 years [7]. In this respect it is noteworthy that all respondents from Hungary and Poland in this survey, where the proportion of smokers in the general population had increased since the fall of the Wall in 1989, indicated an increased incidence of GO. Lastly, a recent EUGOGO study compared characteristics of GO patients referred to EUGOGO centres over a 4-month period in 2012 (n = 269) with those referred over the same 4-month period in 2000 (n = 152) [8]. Smoking rates were 40% in both groups. Mild GO (60.5% in 2012 vs. 41.2% in 2000, p < 0.01) and inactive GO (63.2% in 2012 vs. 39.9% in 2000, p < 0.01) were more prevalent in 2012, suggesting a shift to less severe and less active GO in the first decade of the 21st century (Fig. 2). The secular trend to a lower incidence of GO and to less severe GO might be causally related to a decline in the prevalence of smokers, to an earlier diagnosis and treatment of Graves’ hyperthyroidism (facilitated by the introduction of sensitive TSH assays in the 1980s), and to a prudent use of ¹³¹I therapy (which carries a risk of about 15% for de novo development or worsening of GO).

Fig. 2. Characteristics of Graves’ orbitopathy (GO) patients referred to EUGOGO centres in 2012 (grey columns) and in 2000 (white columns), indicating a shift to less active and less severe GO. a GO activity. b GO severity. Reproduced with permission from Perros et al. [8].