Graves’ disease is the most common cause of hyperthyroidism, and Graves’ ophthalmopathy (GO, commonly known as proptosis) is the most important and common extra-thyroidal clinical manifestation of Graves’ disease, with prevalence rates of 16/100,000 and 2.9/100,000 in men and women, respectively. It may precede or coincide with Graves’ hyperthyroidism, and in some cases occurs several years after the onset of hyperthyroidism. In rare cases, it can also occur in patients with Hashimoto’s thyroiditis. As the disease affects the patient’s appearance and, in severe cases, even vision, many patients are often extremely annoyed and fearful about it, so much so that they become overwhelmed and indecisive in their choice of hyperthyroidism treatment modalities. In the prevention and treatment of proptosis, prevention is more valuable than treatment. In recent years, scholars at home and abroad have made remarkable progress in the study of GO, forming a more consistent and feasible prevention and treatment program. This paper outlines the risk factors, clinical activity scores and severity grading for the occurrence and deterioration of GO. On this basis, it proposes preventive and treatment measures, and recommends the most reasonable hyperthyroidism treatment program for patients with hyperthyroidism and proptosis for your reference. Risk factors As far as the current level of knowledge is concerned, the risk factors recognized by the medical community as contributing to the occurrence and development of GO include smoking, pre-treatment hyper-T3emia (≥325 ng/dL or ≥5 nmol/L), excessively high TRAb (TSI>8.8 IU/L), and hypothyroidism due to 131I treatment. Needless to say, recognizing these risk factors is extremely crucial in the prevention of proptosis. Second, activity score and severity grading Clinically, GO can be categorized into inactive GO and active GO based on its activity, and the latter can be further categorized into mild, moderate, severe, and vision-threatening based on its severity. The 2011 ATA and AACE Hyperthyroidism Diagnostic and Treatment Guidelines for clinical activity scores and severity of GO are shown in Tables 1 and 2, respectively; of course, ophthalmologists can be consulted by nuclear medicine or endocrinologists to assist in the diagnosis and treatment of GO. NOTE: Mild GO: has little impact on life and usually does not require immunosuppressive or surgical treatment. Moderate-severe GO: Has a major impact on life and requires immunosuppressive therapy (active) or surgery (inactive). Vision-threatening GO: patients with optic neuropathy and/or corneal rupture III. PREVENTION AND TREATMENT 1. Strict smoking control Smoking is the most important factor that has been proved to cause the occurrence and development of GO, therefore, patients with hyperthyroidism should quit smoking (including passive smoking) as early as possible. 2.Selenite treatment It has been reported in the literature that selenite treatment (200 Vickers/day for 6 months) helps to prevent exacerbation in patients with mild synostosis. 3.Active treatment of hyperthyroidism As both hyperthyroidism and hypothyroidism can lead to the occurrence of proptosis or aggravate the degree of proptosis, for patients with hyperthyroidism associated with GO or hyperthyroidism patients with the risk of developing GO, the thyroid function should be corrected as soon as possible and kept within the normal range, which is extremely important for the prevention and treatment of proptosis. When choosing a treatment for hyperthyroidism in these patients, there is no evidence that 131I therapy, antithyroid medication (methimazole), or thyroidectomy is superior. That is, there is no treatment modality that is inherently more favorable for the management of proptosis. In general, when a patient with hyperthyroidism has an inactive synophthalmos (clinical activity score of less than 3), the choice of 131I therapy, antithyroid medication (methimazole), or thyroidectomy is acceptable; when a patient with hyperthyroidism has an active synophthalmos, the methodology needs to be based on the severity of the synophthalmos and the presence or absence of a risk factor for synophthalmos development and progression. The specific principles are: for patients with hyperthyroidism accompanied by moderately or severely active GO or vision-threatening GO, it is currently recommended to choose a reasonable method of treatment for proptosis along with antithyroid medication or surgical treatment for hyperthyroidism. In contrast, patients with mildly active GO may choose to opt for any of 131I therapy, antithyroid medication (methimazole), or thyroidectomy. Concomitant glucocorticosteroids may be considered when there is mildly active GO but no risk factors, while concurrent glucocorticosteroids must be applied to those who have mildly active GO and risk factors for worsening ocular disease. Thus, it is easy to see that adherence to the principles and consideration of the details are extremely important to the prognosis of patients with hyperthyroidism if 131I therapy is chosen. Since both 131I treatment and the occurrence of hypothyroidism after its treatment are now considered to be risk factors for the development and progression of proptosis, it is reasonable to routinely administer glucocorticoid therapy when choosing 131I treatment for hyperthyroidism with mildly active GO. This helps to prevent the exacerbation of proptosis, to prevent and alleviate the patient’s discomfort caused by radiation thyroiditis triggered by 131I therapy, to control and prevent the risk of hyperthyroid crisis, and to ensure and improve the one-time cure rate of patients with significant thyroid enlargement. Glucocorticosteroids should be used as follows: Prednisone 0.4-0.5mg/kg body weight per day, starting on the day of starting 131I treatment, continuing for 1 month, and then decreasing the dosage every 2 months.