Decrease in Bone Formation and Bone Resorption during Intravenous Methylprednisolone Pulse Therapy in Patients with Graves' Orbitopathy

Background: Treatment with glucocorticoids (GCs) is associated with side effects. In contrast to the well-known negative impact on bone tissue exerted by oral GCs, few data are available regarding intravenous GCs. We investigated the influence of intravenous methylprednisolone (IVMP) on bone turnover markers (BTM): amino-terminal propeptide of type I procollagen (P1NP) and the C-terminal telopeptide of type I collagen (CTX), and on calcium metabolism parameters: 1,25-dihydroxyvitamin D (1,25(OH)2D), 25-hydroxyvitamin D (25(OH)D), calcium (Ca), phosphate (P), and intact parathormone (iPTH). Methods: In a prospective study, 23 consecutive subjects with Graves’ orbitopathy were included and treated with IVMP according to the European Group on Graves’ Orbitopathy recommendations. We evaluated effects on BTM occurring during the first 7 days after 0.5 g IVMP, and after the therapy with 12 IVMP pulses with a cumulative dose of 4.5 g. Results: We observed prompt but transient decrease of P1NP (p < 0.001) and the reduction of CTX (p = 0.02) after the first IVMP pulse. Following the full course of IVMP therapy, both P1NP and CTX were found decreased (p < 0.05 and p < 0.01, respectively). Conclusions: A single pulse of 0.5 g IVMP already decreases bone formation and resorption; however, this change is transient. The full therapy is associated with suppression of bone turnover.

TSAb/TRAb ratio as a sensitive screening test for active Graves' orbitopathy

OBJECTIVE

Graves' orbitopathy (GO), an extrathyroidal manifestation of Graves' disease, can seriously threaten the patient's quality of life. Given that immunosuppressive treatment during the early active phase of GO has been found to reduce both disease activity and severity, sensitive screening tests are needed.

METHODS

The present study included 86 patients with GO, in whom serum levels of thyroid-stimulating hormone (TSH), free T3, free T4, thyroid-stimulating antibody, TSH receptor antibody, thyroid peroxidase antibody, thyroglobulin, and thyroglobulin antibody were measured within 2 months before magnetic resonance imaging (MRI)for orbit assessment.

RESULTS

The thyroid-stimulating antibody/TSH receptor antibody ratio was able to distinguish MRI results with a correct classification rate of 81%. When focusing on patients without T3 predominant Graves' diseases, the ratio distinguished MRI results at a rate of 92%. Receiver operating characteristic curve analysis revealed a cutoff antibody ratio of 87, which yielded a sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 91%, 95%, 18.2, and 0.0957, respectively, for distinguished MRI results.

CONCLUSIONS

The thyroid-stimulating antibody/TSH receptor antibody ratio is a highly sensitive and specific indicator for active GO, especially in patients without T3 predominance, and serves as a good screening test for active GO in primary care settings.

Assessment of serum dipeptidyl peptidase-IV levels in autoimmune thyroid disease

OBJECTIVE

Decreased serum dipeptidyl peptidase-IV (sDPPIV) levels have been reported in patients with autoimmune diseases. However, few studies have analyzed the association between sDPPIV levels and autoimmune thyroid disease (AITD). This study aimed to evaluate the association between sDPPIV levels and three types of AITD: Graves' disease (GD), Graves' ophthalmopathy (GO), and Hashimoto's thyroiditis (HT).

METHODS

Patients newly diagnosed with GD (n = 65), GO (n = 22), and HT (n = 27) and healthy individuals (n = 30) were recruited. Clinical characteristics and thyroid function data were collected. sDPPIV was measured using enzyme-linked immunosorbent assays.

RESULTS

Compared with controls (786.3 ± 46.95), patients with GD and GO had significantly lower sDPPIV levels (662.2 ± 38.81 and 438.4 ± 31.78). Additionally, sDPPIV levels were negatively associated with antithyroid peroxidase antibody (r = -0.20) and antithyroglobulin antibody (r = -0.19), but there was no significant relationship between thyroid hormone and sDPPIV levels. GO cases were divided by proptosis with and without muscle thickening; sDPPIV levels were lower in the muscle thickening group than those in the without muscle thickening group. Logistic regression analysis showed that sDPPIV was negatively correlated with GO and GD.

CONCLUSIONS

sDPPIV concentrations were abnormal in patients with GD and GO, and reduced sDPPIV expression may be involved in the progression of GO and GD.

Topical anaesthesia in strabismus surgery for Graves' orbitopathy: a comparative study of 111 patients

PURPOSE

To evaluate the tolerability and usability of topical anaesthesia in single rectus muscle recession for strabismus caused by Graves' orbitopathy (GO). To compare the perioperative pain score and surgical outcome between GO patients and non-GO patients.

METHODS

A retrospective comparative study of consecutive single rectus muscle recession performed under topical anaesthesia was carried out. All patients scheduled for one-stage single rectus muscle recession under topical anaesthesia were included. Numerical visual analogue pain score scale (NVAS) points, rates of motor success (horizontal deviation < 8 prism diopters (PD) and vertical deviation ≤ 6 PD) and sensory success (no diplopia without prisms), complications and postoperative adjustment frequencies were compared between GO and non-GO patients.

RESULTS

A total of 111 patients were included. The mean perioperative pain scores were 2.3 (SD ± 1.3) in GO and 1.6 (SD ± 1.1) in non-GO patients (p = 0.06 adjusted for gender). The postoperative mean alignments in GO and non-GO patients were 2 versus 3 PD horizontally and 1 versus 1 PD vertically respectively. Both motor and sensory success rates were 98% in GO patients and 94% versus 93% in non-GO patients. Adjustments as a second procedure the day after surgery was performed in 10% of the GO patients and 15% of the non-GO patients. The oculocardiac reflex was not triggered in any of the GO patients.

CONCLUSION

Topical anaesthesia in single muscle recession for GO is safe, well-tolerated and gives comparable surgical outcomes to those achieved in non-GO patients.

A systematic review of multimodal clinical biomarkers in the management of thyroid eye disease

Thyroid Eye Disease (TED) is an autoimmune disease that affects the extraocular muscles and periorbital fat. It most commonly occurs with Graves' Disease (GD) as an extrathyroidal manifestation, hence, it is also sometimes used interchangeably with Graves' Ophthalmopathy (GO). Well-known autoimmune markers for GD include thyroid stimulating hormone (TSH) receptor antibodies (TSH-R-Ab) which contribute to hyperthyroidism and ocular signs. Currently, apart from radiological investigations, detection of TED is based on clinical signs and symptoms which is largely subjective, with no established biomarkers which could differentiate TED from merely GD. We evaluated a total of 28 studies on potential biomarkers for diagnosis of TED. Articles included were published in English, which investigated clinical markers in tear fluid, orbital adipose-connective tissues, orbital fibroblasts and extraocular muscles, serum, thyroid tissue, as well as imaging biomarkers. Results demonstrated that biomarkers with reported diagnostic power have high sensitivity and specificity for TED, including those using a combination of biomarkers to differentiate between TED and GD, as well as the use of magnetic resonance imaging (MRI). Other biomarkers which were upregulated include cytokines, proinflammatory markers, and acute phase reactants in subjects with TED, which are however, deemed less specific to TED. Further clinical investigations for these biomarkers, scrutinising their specificity and sensitivity on a larger sample of patients, may point towards selection of suitable biomarkers for aiding detection and prognosis of TED in the future.

Network Meta-Analysis of Different Intravenous Glucocorticoid Regimes for the Treatment of Graves' Orbitopathy

Background: Intravenous glucocorticoid (GC) has been proposed to treat moderately severe Graves' orbitopathy (GO); however, the optimal regime remains debatable. We therefore performed this network meta-analysis to objectively determine the comparative efficacy and safety of different intravenous GC regimes, including daily, weekly, or monthly intravenous regimes, for the treatment of GO. Methods: We electronically searched Medline (via PubMed), EMBASE (via OVID), and the Cochrane Central Register of Controlled Trials (CENTRAL) (via OVID) to retrieve randomized controlled trials (RCTs) investigating the comparative efficacy and safety of different intravenous GC regimes in GO patients from the inception of each database to March 2021. The latest search was updated in June 2021. The risk of bias of original studies was assessed using the Cochrane risk bias assessment tool. A random-effects Bayesian network meta-analysis was conducted using the Markov chain Monte Carlo (MCMC) simulation. Ranking probabilities of all regimes were calculated to rank all regimes. Statistical analysis was conducted using the ADDIS software. Results: A total of 10 studies involving 593 patients met the selection criteria. Network meta-analysis suggested that the weekly intravenous GC regime (WR) [response: odds ratio (OR), 4.27; 95% creditable interval (CrI); 1.82 to 11.02; clinical activity score change (CASC): standard mean difference (SMD), -0.59; 95% CrI; -1.19 to -0.03) and monthly intravenous regime (MR) (response: OR, 6.32; 95% CrI; 1.25 to 34.96; CASC: SMD, -1.17; 95% CrI; -2.32 to -0.01) were superior to the oral GC (OGC) regime in response and CASC. Meanwhile, pooled results also indicated that the WR was related to the decreased risk of AEs compared with the OGC regime (OR, 0.22; 95% CrI; 0.08-0.62) and daily intravenous GC regime (DR) (OR, 0.19; 95% CrI; 0.03-0.97). Ranking probabilities indicated that the MR and WR have a relatively higher probability of becoming the best option for response, proptosis, and AEs. Conclusion: Based on limited evidence, the WR or MR should be preferentially prescribed to treat patients with moderately severe GO. However, more studies with a large sample size should be conducted to further confirm our findings and compare the WR with the MR.

Thicknesses of the retinal layers in patients with Graves' disease with or without orbitopathy

PURPOSE

Graves' orbitopathy (GO) is an inflammatory process that may involve the ocular surface, orbital fat, extraocular muscles, and optic nerves in patients with Graves' disease (GD). We aimed to compare thicknesses of retinal layers in patients with GD with and without GO.

METHODS

One hundred seven patients with GD [23 with GO (Group 1), 84 without GO (Group 2)] and eighteen volunteers (Group 3) were enrolled. The spectral-domain optical coherence tomography (SD-OCT) was used for ophthalmologic evaluation. Seven retinal layers including retinal nerve fibre layer (RNFL), ganglion cell layer (GCL), inner plexiform layer (IPL), inner nuclear layer (INL), outer plexiform layer (OPL), outer nuclear layer (ONL), retinal pigment epithelium (RPE) were assessed. The thicknesses of layers were compared in groups.

RESULTS

The median GCL thickness values in groups 1, 2, and 3 were 14 µm, 15 µm, and 17.5 µm, respectively (p = 0.02). The median IPL thickness was 20 µm in group 1, 21 µm in group 2, and 22 µm in group 3 (p = 0.038). The median RPE thickness values in groups 1, 2, and 3 were 16 µm, 17 µm, and 18.5 µm, respectively (p = 0.001). GCL in group 1 was thinner than in group 3 (p = 0.02), while similar in groups 2 and 3 (p = 0.06). IPL in group 1 was thinner than in group 3 (p = 0.035), while similar in groups 2 and 3 (p = 0.13). RPE in groups 1 and 2 was thinner than in group 3 (p = 0.009, p = 0.001, respectively), while it was similar in groups 1 and 2 (p = 0.93). RNLF, INL, OPL, ONL were similar in all three (p > 0.05 for each).

CONCLUSION

Ganglion cell layer and IPL were thinner in patients with GO than in healthy controls, while both were similar in patients without GO and healthy controls. RPE was thinner in all Graves patients than in healthy controls. Early detection of changes in retinal layers of GD may guide the physician to prevent significant vision problems.

Dysthyroid Optic Neuropathy: Treatment with Additional Intravenous Methylprednisolone Pulses after the Basic Schedule Is Associated with Stabilization or Further Improvement of Clinical Outcome

Background: Dysthyroid optic neuropathy (DON) is a sight-threatening complication of Graves’ orbitopathy (GO). Treatment of DON consists of the urgent administration of intravenous methylprednisolone (ivMP) in very high doses followed by orbital decompression if the response is poor or absent. It is advised to continue the therapy with pulses of ivMP in a weekly schedule. The purpose of this study was to evaluate the impact of the additional treatment with ivMP in a 12-week protocol on visual acuity (VA), color vision, clinical activity score (CAS) and proptosis in patients with DON. Methods: This study was performed on 19 patients with DON (26 eyes) treated with ivMP in very high doses, with further orbital decompression in 11 individuals (15 eyes). VA, color vision, CAS and proptosis were evaluated prior to the DON treatment, before and after the 12-week ivMP (first and last pulse). Additionally follow up was performed (22 eyes). Results: VA and color vision improved between the first and last pulse of the additional ivMP treatment (p = 0.04 and p = 0.003, respectively). CAS and proptosis were reduced at the end of the 12-week ivMP therapy compared to observations at the beginning (p < 0.001 and p = 0.04, respectively). Follow up confirmed stabilization of this achievement. Conclusions: The results of this study suggest that additional treatment with 12 pulses of ivMP improves or stabilizes the outcome of basic therapy in patients with DON.

A case of Graves' disease presenting with internal ophthalmoplegia during methylmercaptoimidazole treatment

A 28-year-old Japanese woman positive for TSH receptor antibody and anti-nuclear antibody complained of difficulty seeing nearby objects, severe throbbing retro-orbital pain, diplopia, blepharoptosis and upward gaze palsy when she became hypothyroid during treatment with 30 mg methylmercaptoimidazole for Graves' hyperthyroidism. Brain magnetic resonance imaging revealed slightly swollen bilateral inferior rectus muscles, suggesting the external ophthalmoplegia due to the muscle pathology commonly encountered in Graves' disease. The retro-orbital pain was associated with marked accommodation failure and the pupillary abnormalities. The left and/or right eye showed intermittent, asymmetric and fluctuating mydriasis, being unresponsive to ordinary light but slowly responsive to strong sunlight and slowly responsive in a dark room. During the 5-year period, mydriasis was observed 9 times on both sides, 11 times only on the right side and 4 times only on the left side. Internal ophthalmoplegia with tonic pupils and accommodation failure affecting both the pupillary sphincter muscle and ciliary muscle due to damage to the parasympathetic outflow to these muscles was suggested. Autoimmune mechanism and/or the mechanism underlying channelopathy affecting the ciliary ganglion or short ciliary nerves might be responsible for this fluctuating complication. This very rare panophthalmopathy affecting both external and internal muscles occurred when the patient was suffering from iatrogenic hypothyroidism during the 30 mg methylmercaptimidazole treatment for Graves' disease.

Upper Eyelid Retraction in Graves' Ophthalmopathy: Our Surgical Experience on 153 Cases of Full-Thickness Anterior Blepharotomy with Mullerectomy

BACKGROUND

We present our experience on 153 cases of full-thickness anterior blepharotomy with mullerectomy (FTABM) in the treatment of upper eyelid retraction (UER) related to Graves' ophthalmopathy (GO).

METHODS

We included all the patients who underwent a graded FTABM between 1^st January 2015 and 30^th June 2020 for UER GO-related. The analysis included: pre-/post-operative conjunctival symptoms, epiphora, GO-Quality of Life Questionnaire (QoL), lagophthalmos, marginal reflex distance (MRD-1) index, eyelid symmetry within 1mm. The statistical analysis was designed to detect postoperative improvement in objective and subjective clinical features. Outcomes were analysed through Chi-squared test for dichotomous variables and through Wilcoxon-Mann-Whitney test for continuous variables.

RESULTS

Of the 111 patients, 42 underwent a bilateral procedure, while 69 a monolateral. Conjunctival symptoms were reported in 32% of cases before surgery and in 12.4% after FTABM (p < 0.001). Epiphora was complained by 29.6% of patients preoperatively and in 12.4% postoperatively (p < 0.001). Preoperative lagophthalmos was found in 12.4% (mean value of 0.34 ± 0.76 mm) of eyelids, and in 2.6% (mean value 0.05 ± 0.19 mm) eyelids (p = not significant) postoperatively. Pre-operative GO-QoL was 24.9 ± 4.4 mm; while post-operative GO-QoL was 35.3 ± 5.5 mm (p < 0.001). The MRD-1 varied from 10.12 ± 2.1 mm preoperatively, to 4.3 ± 0.6 mm (p < 0.001) after surgery. Asymmetric palpebral fissure was noted in 94 (84.7%) patients before surgery and in 7 (6.3%) after the procedure (p < 0.001).

CONCLUSION

FTABM is an effective procedure to treat UER GO-related. The technique manages to prevent complications of UER and determine good aesthetics.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . Level IV, therapeutic study.

2021 update on thyroid-associated ophthalmopathy

PURPOSE

Our understanding of thyroid-associated ophthalmopathy (TAO, A.K.A Graves' orbitopathy, thyroid eye disease) has advanced substantially, since one of us (TJS) wrote the 2010 update on TAO, appearing in this journal.

METHODS

PubMed was searched for relevant articles.

RESULTS

Recent insights have resulted from important studies conducted by many different laboratory groups around the World. A clearer understanding of autoimmune diseases in general and TAO specifically emerged from the use of improved research methodologies. Several key concepts have matured over the past decade. Among them, those arising from the refinement of mouse models of TAO, early stage investigation into restoring immune tolerance in Graves' disease, and a hard-won acknowledgement that the insulin-like growth factor-I receptor (IGF-IR) might play a critical role in the development of TAO, stand out as important. The therapeutic inhibition of IGF-IR has blossomed into an effective and safe medical treatment. Teprotumumab, a β-arrestin biased agonist monoclonal antibody inhibitor of IGF-IR has been studied in two multicenter, double-masked, placebo-controlled clinical trials demonstrated both effectiveness and a promising safety profile in moderate-to-severe, active TAO. Those studies led to the approval by the US FDA of teprotumumab, currently marketed as Tepezza for TAO. We have also learned far more about the putative role that CD34+ fibrocytes and their derivatives, CD34+ orbital fibroblasts, play in TAO.

CONCLUSION

The past decade has been filled with substantial scientific advances that should provide the necessary springboard for continually accelerating discovery over the next 10 years and beyond.

A Tear Metabolomic Profile Showing Increased Ornithine Decarboxylase Activity and Spermine Synthesis in Thyroid-Associated Orbitopathy

About half of patients with Graves’ disease develop an orbitopathy related to an inflammatory expansion of the periorbital adipose tissue and muscles. We used a targeted metabolomic approach measuring 188 metabolites by mass spectrometry to compare the metabolic composition of tears in patients with active (n = 21) versus inactive (n = 24) thyroid-associated orbitopathy. Among the 44 metabolites accurately measured, 8 showed a significant alteration of their concentrations between the two groups. Two short-chain acylcarnitines, propionylcarnitine and butyrylcarnitine, and spermine showed increased concentrations in the tears of patients with active orbitopathy, whereas ornithine, glycine, serine, citrulline and histidine showed decreased concentrations in this group. In addition, the ratio putrescine/ornithine, representing the activity of ornithine decarboxylase, was significantly increased in patients with active compared to inactive orbitopathy (p = 0.0011, fold change 3.75). The specificity of this candidate biomarker was maintained when compared to a control group with unclassified dry eye disease. Our results suggest that the stimulation of ornithine decarboxylase by TSH receptor autoantibodies in orbital fibroblasts could lead to increased synthesis of spermine, through the increased activity of ornithine decarboxylase, that may contribute to periorbital expansion in Graves’ ophthalmopathy.

A Novel Competing Endogenous RNA Network Associated With the Pathogenesis of Graves' Ophthalmopathy

Background: Growing evidence has recently revealed the characteristics of long noncoding (lncRNA)/circular RNA (circRNA)-microRNA (miRNA)-mRNA networks in numerous human diseases. However, a scientific lncRNA/circRNA-miRNA-mRNA network related to Graves’ ophthalmopathy (GO) remains lacking.

Materials and methods: The expression levels of RNAs in GO patients were measured through high-throughput sequencing technology, and the results were proven by quantitative real-time PCR (qPCR). We constructed a protein-protein interaction (PPI) network using the Search Tool for the Retrieval of Interacting Genes (STRING) database and identified hub genes by the Cytoscape plug-in CytoHubba. Then, the miRNAs related to differentially expressed lncRNAs/circRNAs and mRNAs were predicted through seed sequence matching analysis. Correlation coefficient analysis was performed on the interesting RNAs to construct a novel competing endogenous RNA (ceRNA) network.

Results: In total, 361 mRNAs, 355 circRNAs, and 242 lncRNAs were differentially expressed in GO patients compared with control patients, 166 pairs were identified, and ceRNA networks were constructed. The qPCR results showed that 4 mRNAs (THBS2, CHRM3, CXCL1, FPR2) and 2 lncRNAs (LINC01820:13, ENST00000499452) were differentially expressed between the GO patients and control patients.

Conclusion: An innovative lncRNA/circRNA-miRNA-mRNA ceRNA network between GO patients and control patients was constructed, and two important ceRNA pathways were identified, the LINC01820:13-hsa-miR-27b-3p-FPR2 ceRNA pathway and the ENST00000499452-hsa-miR-27a-3p-CXCL1 pathway, which probably affect the autoimmune response and inflammation in GO patients.

Thyroid-Associated Orbitopathy: Management and Treatment

Thyroid-associated orbitopathy (TAO) is a leading cause of orbital and strabismus symptoms in adults. Over the last decade, new treatments have greatly changed available options to alleviate symptoms and improve outcomes. This article discusses the pathophysiology and natural disease course of TAO, including when to pursue urgent treatment and when to consider other diagnoses. This article highlights the interventions that may alter the disease course and offers a comprehensive review on evidence-based interventions for both supportive therapy and systemic agents. The surgical strategies and principles for the treatment of TAO are discussed, including indications for combined surgical interventions and varying surgical techniques.

Dihydroartemisinin Exerts Antifibrotic and Anti-Inflammatory Effects in Graves' Ophthalmopathy by Targeting Orbital Fibroblasts

Graves' ophthalmopathy (GO) is a common orbital disease that threatens visual function and appearance. Orbital fibroblasts (OFs) are considered key target and effector cells in GO. In addition, hyaluronan (HA) production, inflammation, and orbital fibrosis are intimately linked to the pathogenesis of GO. In this study, we explored the therapeutic effects of dihydroartemisinin (DHA), an antimalarial drug, on GO-derived, primary OFs. CCK8 and EdU assays were applied to evaluate the antiproliferative effect of DHA on OFs. Wound healing assays were conducted to assess OF migration capacity, while qRT-PCR, western blotting, ELISA, and immunofluorescence were used to determine the expression of fibrosis-related and pro-inflammatory markers in these cells. Moreover, RNA sequencing was conducted to identify differentially expressed genes (DEGs) in DHA-treated OFs, and Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis of DEGs was performed to explore potential mechanisms mediating the antifibrotic effect of DHA on GO-derived OFs. Results showed that DHA dose-dependently inhibited OF proliferation and downregulated, at the mRNA and protein levels, TGF-β1-induced expression of fibrosis markers, including alpha smooth muscle actin (α-SMA) and connective tissue growth factor (CTGF). Furthermore, DHA inhibited TGF-β1 induced phosphorylation of extracellular signal-regulated protein kinase 1/2 (ERK1/2) and signal transducer and activator of transcription 3 (STAT3), which suggested that DHA exerted antifibrotic effects via suppression of the ERK and STAT3 signaling pathways. In addition, DHA suppressed the expression of pro-inflammatory cytokines and chemokines, including IL-6, IL-8, CXCL-1, MCP-1, and ICAM-1, and attenuated HA production induced by IL-1β in GO-derived OFs. In conclusion, our study provides first-time evidence that DHA may significantly alleviate pathogenic manifestations of GO by inhibiting proliferation, fibrosis- and inflammation-related gene expression, and HA production in OFs. These data suggest that DHA may be a promising candidate drug for treatment of GO.

The Role of Oxidative Stress and Therapeutic Potential of Antioxidants in Graves' Ophthalmopathy

Graves’ ophthalmopathy (GO) is the most common extrathyroidal manifestation of Graves’ disease. It is characterized initially by an inflammatory process, followed by tissue remodeling and fibrosis, leading to proptosis, exposure keratopathy, ocular motility limitation, and compressive optic neuropathy. The pathogenic mechanism is complex and multifactorial. Accumulating evidence suggests the involvement of oxidative stress in the pathogenesis of GO. Cigarette smoking, a major risk factor for GO, has been shown to induce reactive oxygen species (ROS) generation and oxidative damage in GO orbital fibroblasts. In addition, an elevation in ROS and antioxidant enzymes is observed in tears, blood, and urine, as well as orbital fibroadipose tissues and fibroblasts from GO patients. In vitro and in vivo studies have examined the efficacy of various antioxidant supplements for GO. These findings suggest a therapeutic role of antioxidants in GO patients. This review summarizes the current understanding of oxidative stress in the pathogenesis and potential antioxidants for the treatment of GO.

Efficacy and Safety of Teprotumumab in Thyroid Eye Disease

Thyroid eye disease (TED; also known as thyroid-associated ophthalmopathy) is an autoimmune condition with disabling and disfiguring consequences. Teprotumumab is the first and only medication approved by the United States Food and Drug Administration for the treatment of TED. We review the efficacy and safety of teprotumumab in TED, highlighting results from the 2 randomized, double-masked, placebo-controlled trials. Post-approval case reports of teprotumumab use in patients with compressive optic neuropathy (CON) and inactive TED were similarly favorable to those from the trials. The preliminarily results of teprotumumab for CON and inactive TED should be investigated in formal clinical trials. Teprotumumab should be avoided in pregnancy. Evidence also suggests that teprotumumab may exacerbate pre-existing inflammatory bowel disease, worsen hyperglycemia, and be associated with hearing impairment. Patients at risk for these adverse events need to be closely monitored with baseline and periodic assessments.

The risk factors for Graves' ophthalmopathy

PURPOSE

This review aimed to provide an overview of current research into the risk factors for Graves' ophthalmopathy (GO).

METHODS

To find information about the risk factors for GO, the research database PubMed was searched and relevant articles were obtained to extract information about risk factors.

RESULTS

Smoking has been widely accepted as an important risk factor and cigarette smoking cessation has been shown to improve the outcome and decrease the onset of GO. Radioactive iodine on the thyroid may induce hyperthyroidism and increase the occurrence of GO. Selenium deficiency is a risk factor for GO and the supplementation of selenium has been an adjuvant therapy. Decreasing stressful life events (SLE) may help improve GO. Imbalance in intestinal flora is essential to GO, with Yersinia enterocolitica and Escherichia coli both increased in the digestive tract of the individual with GO. In addition, controlling serum cholesterol may help improve GO since adipogenesis is an important pathological change in its pathogenesis. Considering the correlation between Graves' disease and GO, maintaining normal thyroid function hormone level is the first-line therapeutic strategy to prevent progression of GO. An increase in antibodies such as TSHR and IGF-1R is the main predictor of GO. Besides, gender and gene polymorphism are also risk factors towards GO.

CONCLUSIONS

Risk factors for GO arise from five sources: physical and chemical environment, social-psychological environment, biological environment, the human organism, and genetic codes. Risk factors within these categories may interact with each other and their mechanisms in promoting the development of GO are complex. Research into risk factors for GO may promote emerging fields related to GO such as control of autoantibodies and intestinal microbiota.

Immunotherapy with a biologically active ICAM-1 mAb and an siRNA targeting TSHR in a BALB/c mouse model of Graves' disease

Objective To study targeted therapies using a biologically active monoclonal antibody against intracellular adhesion molecule-1 (ICAM-1 mAb) and an siRNA targeting thyroid-stimulating hormone (TSH) receptor (TSHR) in a BALB/c mouse model of Graves' disease (GD). Methods An improved method for establishing a stable model of GD in BALB/c mice was developed by immunization with pcDNA 3.1/TSHR 289 and electroporation (EP). The mice in which GD was successfully established were divided into a nontreated control group, which was treated with continuous immunization, and treated groups, which were treated with the siRNA and ICAM-1 mAb. Normal mice were included as a blank group. These groups were used to compare the effects of treatment with the ICAM-1 mAb and siRNA. Results The two novel treatments markedly improved weight loss, serum thyroxine (T4) levels, thyroid-stimulating hormone antibody (TSAb) levels, thyroid-stimulating blocking antibody (TSBAb) levels and thyroid uptake of 99mTcO4 in GD model mice. Compared with the siRNA treatment, treatment with the ICAM-1 mAb produced more obvious benefits. The differences in the posttreatment indexes between the two treatment groups were statistically significant (P<0.05). Conclusions These preliminary data suggest that both the biologically active ICAM-1 mAb and the siRNA targeting TSHR were effective. The ICAM-1 mAb exerted a better therapeutic effect than the siRNA targeting TSHR. Both treatments showed potential efficacy as novel treatments for GD and may therefore represent therapeutic options in addition to the existing drugs or interventions.

Clinical relevance of serum immunoglobulin G4 in glucocorticoid therapy of Graves' ophthalmopathy

OBJECTIVE

Previous study suggested IgG4 levels were associated with the development of Graves' ophthalmopathy (GO). The aims of the present study were to investigate the role of IgG4 levels in glucocorticoid (GC) treatment in GO patients.

DESIGN

69 GO patients were enrolled. Serum thyroid hormones, thyroid antibodies, IgG, IgG4, ophthalmological examinations and orbital MRI were performed. Furthermore, the clinical outcomes (a composite response endpoint including the clinical activity score (CAS), proptosis, vision, intraocular pressure, diplopia and lid width) after high-dose intravenous GC treatment in 32 active moderate-to-severe GO patients were compared.

PATIENTS

69 consecutive patients with GO were asked to participate in the study. 32 of 69 GO patients were treated with high-dose intravenous GCs.

MEASUREMENTS

Measurement of serum IgG and IgG4, serum thyroid hormones and thyroid autoantibodies. An overall ophthalmic assessment was performed pretherapy (week 0) and post-therapy (week 12).

RESULTS

33.3% of GO patients (23/69) had elevated IgG4 levels. IgG4 levels were positively correlated with the severity and activity of GO. After GC therapy, IgG4, IgG4/IgG, vision and CAS were significantly improved in GO patients. Patients with high IgG4 levels had a significantly reduced extraocular muscle area (EOMs) and better clinical outcomes than patients with normal IgG4 levels.

CONCLUSIONS

Our results suggest a possible subgroup of elevated IgG4 GO patients, with more severe ophthalmopathy and better response to GCs treatment compare with normal IgG4 GO patients.

Effect of Pirfenidone on TGF-β1-Induced Myofibroblast Differentiation and Extracellular Matrix Homeostasis of Human Orbital Fibroblasts in Graves' Ophthalmopathy

Pirfenidone is a pyridinone derivative that has been shown to inhibit fibrosis in animal models and in patients with idiopathic pulmonary fibrosis. Its effect on orbital fibroblasts remains poorly understood. We investigated the in vitro effect of pirfenidone in transforming growth factor-β1 (TGF-β1)-induced myofibroblast transdifferentiation and extracellular matrix (ECM) homeostasis in primary cultured orbital fibroblasts from patients with Graves' ophthalmopathy (GO). The expression of fibrotic proteins, including α-smooth muscle actin (α-SMA), connective tissue growth factor (CTGF), fibronectin, and collagen type I, was determined by Western blots. The activities of matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) responsible for the ECM homeostasis were examined. After pretreating the GO orbital fibroblasts with pirfenidone (250, 500, and 750 μg/mL, respectively) for one hour followed by TGF-β1 for another 24 h, the expression of α-SMA, CTGF, fibronectin, and collagen type I decreased in a dose-dependent manner. Pretreating the GO orbital fibroblasts with pirfenidone not only abolished TGF-β1-induced TIMP-1 expression but recovered the MMP-2/-9 activities. Notably, pirfenidone inhibited TGF-β1-induced phosphorylation of p38 and c-Jun N-terminal kinase (JNK), the critical mediators in the TGF-β1 pathways. These findings suggest that pirfenidone modulates TGF-β1-mediated myofibroblast differentiation and ECM homeostasis by attenuating downstream signaling of TGF-β1.

Evaluation of the Effect of Proptosis on Choroidal Thickness in Graves' Ophthalmopathy

Objectives:

To evaluate the effect of proptosis on choroidal thickness in patients with Graves’ ophthalmopathy.

Materials and Methods:

Twenty-five eyes of 25 Graves’ patients with proptosis, 25 eyes of 25 Graves’ patients without proptosis, and 25 eyes of 25 healthy individuals were included in this prospective study. The subfoveal choroidal thickness and choroidal thicknesses at 6 points from the fovea at 500 μm intervals were measured by Cirrus HD-OCT. All measurements were compared among the proptosis, non-proptosis, and control groups and the active, inactive, and control groups.

Results:

The mean subfoveal choroidal thickness in the proptosis group was 289.7±68.5 μm, 322.5±55.8 μm in the non-proptosis group, and 316.1±63.0 μm in the control group. The mean nasal choroidal thickness was 260.5±63.5 μm in the proptosis group, 293.9±57.9 μm in the non-proptosis group, and 279.5±63.1 μm in the control group. The mean temporal choroidal thickness was 261.8±60.9 μm in the proptosis group, 289.0±51.8 μm in the non-proptosis group, and 287.8±56.2 μm in the control group. Mean choroidal thickness was 264.7±58.5 μm in the proptosis group, 296.2±47.5 μm in the non-proptosis group, and 288.3±55.1 μm in the control group. There were no statistically significant differences among the groups with respect to choroidal thickness measurements (p>0.05).

Conclusion:

No significant difference in choroidal thickness was detected between Graves’ patients with and without proptosis and the controls. There was no effect of clinical activation on choroidal thickness.

Serum thyroglobulin is associated with orbitopathy in Graves' disease

PURPOSE

Serum thyroglobulin levels are often elevated in Graves' disease (GD) and in most cases decrease during treatment. Its relation to Graves' orbitopathy (GO) has not been clarified. Previously, a risk of GO has been linked to smoking, TSH receptor stimulation, high TSH-receptor antibodies (TRAb), low thyroid peroxidase and thyroglobulin antibodies (TPOAb, TgAb).

METHODS

We examined Tg levels in 30 consecutive patients with GD were given drug therapy (methimazole + thyroxine) for up to 24 months. GO was identified by clinical signs and symptoms. 17 patients had GO, 11 of whom had it at diagnosis while 6 developed GO during treatment. During the study, 5 subjects were referred to radioiodine treatment, 3 to surgery. The remaining 22 subjects (GO n = 12, non-GO n = 10) completed the drug regimen.

RESULTS

At diagnosis, Tg levels in GO patients (n = 11) were higher (84, 30-555 µg/L, median, range) than in non-GO patients (n = 19) (38, 3.5-287 µg/L), p = 0.042. Adding the 6 subjects who developed eye symptoms during treatment to the GO group (n = 17), yielded p = 0.001 vs. non-GO (n = 13). TRAb tended to be higher, while TPOAb and TgAb tended to be lower in the GO group. For the 22 patients who completed the drug regimen, Tg levels were higher in GO (n = 12) vs. non-GO (n = 10), p = 0.004, whereas TRAb levels did not differ.

CONCLUSION

The data may suggest that evaluation of thyroglobulin levels in GD could contribute to identify patients at increased risk of developing GO. Possibly, thyroidal release of Tg in GD reflects a disturbance that also impacts retroorbital tissues.

[Monoclonal antibodies in the treatment of thyroid eye disease]

Thyroid eye disease (TED) is an autoimmune condition affecting extraocular muscles and orbital fat that is most often a manifestation of the Graves' disease or Hashimoto thyroiditis. This disease significantly worsens the quality of life of patients, and therefore requires the use of effective treatment methods. Traditional therapy involves glucocorticosteroids and x-rays aimed at reducing the inflammatory process, rather than proptosis and diplopia, while targeted therapy is better able to influence the clinical course of the disease. The review presents a modern understanding of the pathogenesis of TED and analysis of clinical studies concerning the use of monoclonal antibodies for its treatment.