AAO 2026: Imaging pearls for thyroid eye disease

Choosing between computed tomography (CT) and magnetic resonance imaging (MRI) in thyroid eye disease (TED) depends on the clinical question, and clinicians should always review the images themselves, according to Liza M. Cohen, MD, an orbital and oculoplastic surgeon and assistant professor of ophthalmology at Northwestern University Feinberg School of Medicine in Chicago, Illinois. At the American Academy of Ophthalmology (AAO) 2026 Annual Meeting in New Orleans, Louisiana, Cohen spoke with Ophthalmology Times about her talk, “Thyroid Eye Disease: Practical Imaging Pearls.” The talk is part of the instruction course “Orbital Imaging: Practical Guidelines for Clinical Decision-Making.”

How should clinicians choose between CT and MRI in TED?

Cohen said it is reasonable to image most, if not all, patients with TED at initial presentation, especially when the diagnosis is uncertain or there are atypical features. CT is quicker than MRI and should be performed without contrast to avoid the risk of worsening active disease with iodine contrast. CT is also useful for patients with significant proptosis who may need bony orbital decompression, because it better images bony anatomy. MRI is preferred when another diagnosis, such as a tumor or other orbital inflammation, is in question, because it better images soft tissue. In dysthyroid optic neuropathy, Cohen often obtains both, because these patients frequently need decompression and MRI helps assess optic nerve inflammation.

The key pitfall to avoid is relying solely on the radiology report. “Always, always, always look at the imaging yourself, especially if there are subtle findings that our radiologists may not pick up,” she said.

How is the TED treatment landscape changing?

Targeted insulin-like growth factor 1 receptor antagonists, including teprotumumab-trbw (Tepezza; Amgen) and veligrotug-vvze (Lumvoa; Viridian Therapeutics), have helped patients avoid surgery or high-dose systemic corticosteroids, or need less surgery, Cohen said. More subcutaneous and oral targeted therapies are in the pipeline. The added options have made counseling “a little more complicated,” she said, but many patients are relieved that corticosteroids or surgery are no longer their only choices. Looking ahead, Cohen expects artificial intelligence to play a growing role in screening orbital imaging and determining whether scans are normal or abnormal. It may also help guide diagnosis.

For more from the meeting, visit Ophthalmology Times’ AAO 2026 coverage.