Thyroid ophthalmopathy (TED) is a common and representative extra thyroid manifestation of Graves′ disease. It is an organ specific autoimmune disease characterized by orbital tissue inflammation, fat hyperplasia, and fibrosis, which can cause significant damage to patients′ visual function and quality of life. In recent years, key breakthroughs have been made in the understanding of its pathogenesis, especially in the elucidation of the signaling cross dialogue network between thyroid stimulating hormone receptor (TSHR) and insulin-like growth factor receptor (IGF), which directly promotes the revolutionary development of targeted biological therapy. The cascade reaction mechanism of TED from autoimmune initiation to tissue remodeling, with a focus on the core roles of TSHR/IGF-1 signaling axis, immune cell infiltration, and immune microenvironment regulation were systematically reviewed in this paper; the clinical research evidence of marketed biologics and other emerging therapies, represented by the monoclonal antibody Tepotumumab targeting IGF-1R were comprehensively sorted out and the main challenges faced by current TED therapy were discussed; the future development directions of precision medicine were prospected, including personalized treatment guided by multiple omics, chimeric antigen receptor T-cell (CAR-T) therapy, and anti fibrotic treatment strategies, aiming to provide reference for TED′s clinical decision-making and translational research.