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To identify clinical predictors of treatment failure in patients with moderate-to-severe or severe Thyroid Eye Disease (TED) following first-line intravenous methylprednisolone (IVMP).

We retrospectively reviewed 23 patients with TED treated with IVMP with or without mycophenolate mofetil (MMF) as per EUGOGO guidelines at Moorfields Eye Hospital (April 2021–December 2022). Treatment ‘Failure’ was defined by development of dysthyroid optic neuropathy (DON), vision loss, or need for emergency decompression. Data was analysed using Fisher’s Exact and Mann-Whitney U tests.

Twenty-three patients were included; 61% (14/23) were female, with a median age of 49.5 (range 37–73) years. Treatment failure occurred in six patients (26.1%).

Patients in the failure group were significantly older than those in the success group (mean 62 vs. 51 years; p=0.034). MMF use was more common in the failure group (50% vs. 5.9%; p=0.028). Smoking prevalence was higher in the failure group (50% vs. 11.8%; p=0.074). Gender and baseline features, including lid retraction, proptosis, intra-orbital swelling, and diplopia, did not differ significantly between groups.

Surgical intervention rates were higher in the failure group for both elective orbital decompression and strabismus surgery (both 50% vs. 17.7%; p=0.152). Within the failure cohort, 83.3% required emergency decompression, 83.3% developed optic neuropathy, 16.7% developed DON, and 33.3% experienced vision loss.

Older age is a predictor of IVMP failure, with limited efficacy of treatment escalation using MMF. Baseline clinical features did not predict progression. Treatment failure is associated with severe morbidity, including DON and vision loss, underscoring the need for early risk stratification and close monitoring. These findings are derived from a small, single-centre cohort; larger real-world studies are required to confirm these associations and define their clinical applicability.