The initial clinical characteristics of Graves' orbitopathy vary with age and sex

Thyroid-associated Orbitopathy: Quantitative Evaluation of the Orbital Fat Volume and Edema Using IDEAL-FSE

Background and Purpose

To compare orbital quantitative data obtained by fast spin-echo iterative decomposition of water and fat with echo asymmetry and least-squares estimation (FSE-IDEAL) in patients with thyroid-associated orbitopathy (TAO) and healthy controls and to investigate the characteristics of these data in TAO patients.

Materials and Methods

Twenty-two TAO patients (4 males and 18 females; median age 51.0 years) and 22 healthy subjects (5 males and 17 females; median age 50.5 years) underwent orbital T2-weighted FSE-IDEAL. The water fraction in orbital fat was defined as the signal intensity (SI) water / (SI water + SI fat). The orbital fat volume was measured on fat images. The degree of proptosis was evaluated using in-phase imaging. Mann–Whitney U test was used to compare these quantitative data in the two groups. In TAO patients we ascertained the correlation among these values with the Spearman's rank correlation coefficient.

Results

In TAO patients, the water fraction (right and left, p = 0.04), fat volume (right and left, p = 0.03) and degree of proptosis (right and left, p < 0.01) were higher than in the controls. In TAO patients, only the water fraction and the fat volume of left orbit showed negative correlation (p = 0.01).

Conclusion

The water fraction of orbital fat, the orbital fat volume and the degree of proptosis obtained with FSE-IDEAL were higher in TAO patients than in the controls. The water fraction was a new parameter for differentiating between TAO patients and healthy subjects.

DISEASE PRESENTATION AND REMISSION RATE IN GRAVES DISEASE TREATED WITH ANTITHYROID DRUGS: IS GENDER REALLY A FACTOR?

OBJECTIVE

Male gender is considered an adverse prognostic factor for remission of Graves disease treatment with antithyroid drugs (ATDs), although published data are conflicting. This often results in early consideration of radioiodine treatment and surgery for men. Our objective was to compare disease presentation and outcome in men versus women treated with ATDs.

METHODS

Retrospective study of 235 patients (64 men, 171 women) with Graves disease who were evaluated for features at presentation and outcome at the end of follow-up between 2010 and 2015.

RESULTS

Disease presentation was similar in men and women for age at diagnosis (41.4 ± 14 years vs. 40 ± 15 years), duration of follow-up (6.6 ± 7 years vs. 7.7 ± 6 years), rates of comorbid autoimmune diseases, and rate of Graves ophthalmopathy. Smoking was more prevalent in males (31% vs. 15%; P = .009). Free thyroxine and triiodothyronine levels were comparable. ATDs were first-line treatment in all males and in 168 of 171 females, for a median duration of 24 and 20 months, respectively ( P = .55). Remission rates were 47% in men and 58% in women ( P = .14). Males had fewer adverse events (9% vs. 18%) and treatment discontinuation (5% vs. 16%). Disease recurrence was comparable (14% vs. 20%; P = .32), as was requirement for second-line treatment, either radioiodine therapy or thyroidectomy.

CONCLUSION

Graves disease presentation is similar in men and women. Men treated with ATDs have high remission rates and similar recurrence rates compared to women, with fewer adverse events and less discontinuation of treatment. ATDs are an attractive first-line treatment for both genders.

ABBREVIATIONS

ATA = American Thyroid Association; ATD = antithyroid drug; GO = Graves ophthalmopathy; T3 = triiodothyronine; T4 = thyroxine; TSH = thyroid-stimulating hormone.

Graves' orbitopathy occurs sex-independently in an autoimmune hyperthyroid mouse model

Graves’ orbitopathy (GO) is the most common extra thyroidal complication of Graves’ disease (GD) and occurs predominantly in women but more severe in men. The reason for this effect of gender on GO is unknown. Herein we studied the manifestation of GO in both sexes of an induced mouse model in absence of additional risk factors present in patients like advanced age, genetic variabilities or smoking. Male and female mice were immunized with human TSHR A-subunit encoding plasmid. Both sexes comparably developed autoimmune hyperthyroidism characterized by TSHR stimulating autoantibodies, elevated T4 values, hyperplastic thyroids and hearts. Autoimmune mice developed inflammatory eye symptoms and proptosis, although males earlier than females. Serial in vivo¹H/¹⁹F-magnetic resonance imaging revealed elevated inflammatory infiltration, increased fat volume and glycosaminoglycan deposition in orbits of both sexes but most significantly in female mice. Histologically, infiltration of T-cells, extension of brown fat and overall collagen deposition were characteristics of GO in male mice. In contrast, female mice developed predominately macrophage infiltration in muscle and connective tissue, and muscle hypertrophy. Apart from sex-dependent variabilities in pathogenesis, disease classification revealed minor sex-differences in incidence and total outcome. In conclusion, sex does not predispose for autoimmune hyperthyroidism and associated GO.

Orbital decompression surgery for the treatment of Graves' ophthalmopathy: comparison of different techniques and long-term results

AIM

To evaluate the long-term results of different orbital decompression techniques performed in patients with Graves' ophthalmopathy (GO).

METHODS

Totally 170 cases with GO underwent orbital decompression between 1994 and 2014. Patients were divided into 4 groups as medial-inferior, medial-lateral (balanced), medial-lateral-inferior, and lateral only according to the applied surgical technique. Surgical indications, regression degrees on Hertel exophthalmometer, new-onset diplopia in the primary gaze and new-onset gaze-evoked diplopia after surgery and visual acuity in cases with dysthyroid optic neuropathy (DON) were compared between different surgical techniques.

RESULTS

The study included 248 eyes of 149 patients. The mean age for surgery was 42.3±13.2y. DON was the surgical indication in 36.6% of cases, and three-wall decompression was the most preferred technique in these cases. All types of surgery significantly decrease the Hertel values (P<0.005). Balanced medial-lateral, and only lateral wall decompression caused the lowest rate of postoperative new-onset diplopia in primary gaze. The improvement of visual acuity in patients with DON did not significantly differ between the groups (P=0.181).

CONCLUSION

The study show that orbital decompression surgery has safe and effective long term results for functional and cosmetic rehabilitation of GO. It significantly reduces Hertel measurements in disfiguring proptosis and improves visual functions especially in DON cases.

Predictive score for the development or progression of Graves' orbitopathy in patients with newly diagnosed Graves' hyperthyroidism

OBJECTIVE

To construct a predictive score for the development or progression of Graves' orbitopathy (GO) in Graves' hyperthyroidism (GH).

DESIGN

Prospective observational study in patients with newly diagnosed GH, treated with antithyroid drugs (ATD) for 18 months at ten participating centers from EUGOGO in 8 European countries.

METHODS

348 patients were included with untreated GH but without obvious GO. Mixed effects logistic regression was used to determine the best predictors. A predictive score (called PREDIGO) was constructed.

RESULTS

GO occurred in 15% (mild in 13% and moderate to severe in 2%), predominantly at 6-12 months after start of ATD. Independent baseline determinants for the development of GO were clinical activity score (assigned 5 points if score > 0), TSH-binding inhibitory immunoglobulins (2 points if TBII 2-10 U/L, 5 points if TBII > 10 U/L), duration of hyperthyroid symptoms (1 point if 1-4 months, 3 points if >4 months) and smoking (2 points if current smoker). Based on the odds ratio of each of these four determinants, a quantitative predictive score (called PREDIGO) was constructed ranging from 0 to 15 with higher scores denoting higher risk; positive and negative predictive values were 0.28 (95% CI 0.20-0.37) and 0.91 (95% CI 0.87-0.94) respectively.

CONCLUSIONS

In patients without GO at diagnosis, 15% will develop GO (13% mild, 2% moderate to severe) during subsequent treatment with ATD for 18 months. A predictive score called PREDIGO composed of four baseline determinants was better in predicting those patients who will not develop obvious GO than who will.

Mortality in Graves' orbitopathy is increased and influenced by gender, age and pre-existing morbidity: a nationwide Danish register study

INTRODUCTION

It is unclear whether the excess mortality associated with Graves' disease differs between individuals with Graves' orbitopathy (GO) or without (GD).

SUBJECTS AND METHODS

A nationwide, register-based cohort study in which all adult Danes diagnosed with GD (n = 28 461) and GO (n = 3965) between 1995 and 2012 were matched for age and gender with four control subjects. Median follow-up time was 7.9 years (range 0-17.5). Mortality risk in GO patients compared to the control population and compared to GD patients was calculated using Cox regression analyses, adjusting for pre-existing morbidity using the Charlson score.

RESULTS

Adjusted mortality in Graves' disease overall (GD + GO) was significantly increased compared to that in the background population (HR = 1.18 (95% confidence interval: 1.15-1.21)). In GD and GO separately, adjusted mortality was also significantly higher than that in their respective control populations (HR: 1.19 (1.16-1.22) and HR: 1.23 (1.12-1.35) respectively). However, mortality in GO compared to that in GD was decreased (HR: 0.64 (0.59-0.69)), although this difference attenuated after adjustment for pre-existing morbidity, age and gender. Both GD and GO males had a significantly higher mortality than those in females. For GO, but not for GD, mortality risk was the highest in the youngest and decreased with increasing age.

CONCLUSIONS

GD and GO were associated with increased mortality, especially in males. In GO, but not in GD patients, there was an inverse relationship between age and mortality. Surprisingly, and in need of further study, mortality was not higher in GO than that in GD individuals.

Clinical characteristics of moderate-to-severe thyroid associated ophthalmopathy in 354 Chinese cases

Thyroid associated ophthalmopathy (TAO) is an autoimmune inflammatory disorder which disfigures appearance, threatens vision, and results in a pronounced loss of quality of life. The diversity and ethnic difference of the disease manifestations have made it difficult to tailor therapies for each patient. Few studies have analyzed its characteristics in Chinese populations. We therefore enrolled 354 patients with moderate-to-severe TAO from February 2015 to July 2016. A single ophthalmologist consistently performed detailed ophthalmic examinations. Orbital computed tomography or magnetic resonance imaging scans were performed to verify enlarged extraocular muscles. Multiple linear regression was used to analyze the association between sex, age, smoking, family history of thyroid diseases, degree of proptosis and disease severity. The mean age of males (46.56±11.08 years) was significantly higher than that of females (41.39±years), with a female-to-male ratio of 1.09. The females and males between 31~40 and 41~50 years, respectively, had the highest incidence of TAO. 81.48% of the patients suffered hyperthyroidism. TAO was diagnosed either after (47.17%) or simultaneously with thyroid dysfunction (27.68%). Proptosis (91.24%), eyelid retraction (83.33%), together with eyelid swelling (79.38%) and extraocular muscle enlargement (75.42%), were the most common clinical sign. 19.77% of patients manifested lower eyelid retraction. The mean values of exophthalmos and asymmetry on proptosis were 19.94±3.45mm and 2.18±2.06mm, respectively in males, 18.58±3.31mm and 1.61±1.53mm, respectively in females. The severity of disease was significantly associated with male, older age, smoking, family history of thyroid diseases and degree of proptosis. We found several differences in Chinese compared with White. The female-to-male ratio and mean value of exophthalmos were significantly lower than the data of White. Inferior and superior rectus became the most common extraocular muscles. Lower eyelid retraction should be included in diagnostic criteria in Asian patients. Understanding these differences, may allow better identification and treatment for TAO in China.

Dysthyroid optic neuropathy: update on pathogenesis, diagnosis, and management

INTRODUCTION

Dysthyroid optic neuropathy (DON) is a severe manifestation of thyroid eye disease (TED) that can result in permanent vision loss. Management is complex, multidisciplinary, and involves medical and/or surgical therapies. This review describes current concepts in the epidemiology, pathophysiology, diagnosis, and treatment of DON.

AREAS COVERED

An extensive review of the literature was performed to detail current concepts on the diagnosis and management of DON. This includes utilization of various medical and surgical modalities for disease management.

EXPERT COMMENTARY

DON can result in permanent blindness and often requires the use of corticosteroids and surgical decompression. We favor the use of intravenous corticosteroids and a transcaruncular approach when surgical decompression is indicated. The use of orbital radiation for DON is often reserved for patients that are poor surgical candidates and/or patients with refractory disease.

Orbital Fat Volumetry and Water Fraction Measurements Using T2-Weighted FSE-IDEAL Imaging in Patients with Thyroid-Associated Orbitopathy

BACKGROUND AND PURPOSE

The quantitative evaluation of orbital fat proliferation and edema and the assessment of extraocular muscles are useful for diagnosing and monitoring thyroid-associated orbitopathy. To evaluate therapy-induced quantitative changes in the orbital fat of patients with thyroid-associated orbitopathy, we performed volumetric and water fraction measurements by using T2-weighted FSE iterative decomposition of water and fat with echo asymmetry and least-squares estimation (FSE-IDEAL) imaging.

MATERIALS AND METHODS

Orbital FSE-IDEAL images of 30 volunteers were acquired twice within 1 week. Nine patients with thyroid-associated orbitopathy underwent FSE-IDEAL imaging before and after methylprednisolone pulse therapy, and the treatment results were assessed by using their pre- and post-methylprednisolone pulse therapy clinical activity scores. We performed volumetric and water fraction measurements of orbital fat by using FSE-IDEAL imaging and evaluated interscan differences in the volunteers. In patients with thyroid-associated orbitopathy, we compared pre- and posttherapy orbital fat measurements and assessed the correlation between the pretherapy values and clinical activity score improvement.

RESULTS

The reproducibility of results obtained by the quantitative evaluation of orbital fat in volunteers was acceptable. After methylprednisolone pulse therapy, the water fraction in the orbital fat of patients with thyroid-associated orbitopathy was significantly decreased (P < .001). There was a significant positive correlation between the pretherapy water fraction and clinical activity score improvement (right, r = 0.82; left, r = 0.79) and a significant negative correlation between the pretherapy volume and clinical activity score improvement (bilateral, r = -0.84).

CONCLUSIONS

Volumetric and water fraction measurements of orbital fat by using FSE-IDEAL imaging are feasible and useful for monitoring the effects of therapy and for predicting the response of patients with thyroid-associated orbitopathy to methylprednisolone pulse therapy.

Thyroid eye disease: a review

Thyroid eye disease is a multifactorial autoimmune disease with a spectrum of signs and symptoms. Oftentimes, the diagnosis of thyroid eye disease is straightforward, based upon history and physical examination. The purpose of this review is to assist the eye-care practitioner in staging the severity of thyroid eye disease (mild, moderate-to-severe and sight-threatening) and correlating available treatment modalities. Eye-care practitioners play an important role in the multidisciplinary team by assessing functional vision while also managing ocular health.

Expression and clinical significance of connective tissue growth factor (CTGF) in Graves' ophthalmopathy

AIMS

To examine the expression of connective tissue growth factor (CTGF) in human cultured orbital fibroblasts from patients with Graves' ophthalmopathy (GO) and investigate whether a correlation exists between the presence of CTGF protein and clinical parameters of the disease.

METHODS

The protein expression levels of CTGF were analysed by western blots in cultured orbital fibroblasts from 10 patients with GO and 7 age-matched normal controls. Associations between the protein expression of CTGF and the clinical factors of GO, including clinical demographics, thyroid function, clinical activity score (CAS) and ophthalmopathy index (OI), was evaluated.

RESULTS

The mean protein expression levels of CTGF in the GO orbital fibroblasts were significantly higher than those of normal controls (p<0.001). Based on further analysis, the protein expression levels of CTGF in the GO orbital fibroblasts had significant correlation with gender (p=0.029), serum levels of thyrotropin receptor antibodies (p=0.029), CAS (p=0.048) and OI (p=0.043). Especially, there was a significant correlation between protein expression levels of CTGF and lid oedema (p=0.037), proptosis (p=0.045) and corneal involvement (p=0.001).

CONCLUSIONS

Our findings revealed that the protein expression levels of CTGF in the GO orbital fibroblasts were significantly highly expressed than those of normal controls, and the elevated CTGF was associated with clinical characteristics and evolution, indicating CTGF may play a role in the pathogenesis and pathophysiology of GO.

Surgical Responses of Medial Rectus Muscle Recession in Thyroid Eye Disease-Related Esotropia

We evaluate the surgical outcomes and surgical responses of medial rectus muscle (MR) recession patients with thyroid eye disease (TED)-related esotropia (ET). The surgical dose-response curves 1 week postoperatively and at the final visit were analyzed. Univariable and multivariable linear regression analyses were applied to investigate factors influencing surgical dose-response. A total of 43 patients with TED-related ET that underwent MR recession were included. The final success rate was 86.0% and the rate of undercorrection was 14.0%. The surgical dose-response curves of TED-related ET showed a gentle slope compared with those of standard surgical tables. In the univariable model, simultaneous vertical rectus muscle recession was the only significant factor influencing surgical dose-response of MR recession in TED-related ET (β = -0.397, P = 0.044). In a model adjusted for age, sex, type of surgery, and preoperative horizontal angle of deviation, simultaneous vertical rectus muscle recession showed marginal significance (β = -0.389, P = 0.064). The surgical dose-response curve of TED-related ET was unique. Simultaneous vertical rectus muscle recession was associated with increased surgical dose-response in TED-related ET.

Pathogenesis of thyroid eye disease: review and update on molecular mechanisms

Orbital changes in thyroid orbitopathy (TO) result from de novo adipogenesis, hyaluronan synthesis, interstitial oedema and enlargement of extraocular muscles. Cellular immunity, with predominantly CD4+ T cells expressing Th1 cytokines, and overexpression of macrophage-derived cytokines, perpetuate orbital inflammation. Orbital fibroblasts appear to be the major effector cells. Orbital fibroblasts express both thyrotropin receptor (TSHR) and insulin-like growth factor-1 receptor (IGF-1R) at higher levels than normal fibroblasts. TSHR expression increases in adipogenesis; TSHR agonism enhances hyaluronan production. IGF-1R stimulation leads to adipogenesis, hyaluronan synthesis and production of the chemokines, interleukin (IL)-16 and Regulated on Activation, Normal T Cell Expression and Secreted, which facilitate lymphocyte trafficking into the orbit. Immune activation uses a specific CD40:CD154 molecular bridge to activate orbital fibroblasts, which secrete pro-inflammatory cytokines including IL-1β, IL-1α, IL-6, IL-8, macrophage chemoattractant protein-1 and transforming growth factor-β, to perpetuate orbital inflammation. Molecular pathways including adenylyl cyclase/cyclic adenosine monophosphate, phophoinositide 3 kinase/AKT/mammalian target of rapamycin, mitogen-activated protein kinase are involved in TO. The emergence of a TO animal model and a new generation of TSHR antibody assays increasingly point towards TSHR as the primary autoantigen for extrathyroidal orbital involvement. Oxidative stress in TO resulting from imbalances of the oxidation-reduction state provides a framework of understanding for smoking prevention, achieving euthyroidism and the use of antioxidants such as selenium. Progress has been made in the understanding of the pathogenesis of TO, which should advance development of novel therapies targeting cellular immunity, specifically the CD40:CD40 ligand interaction, antibody-producing B cells, cytokines, TSHR and IGF-1R and its signalling pathways. Further studies in signalling networks and molecular triggers leading to burnout of TO will further our understanding of TO.

Diagnosis, Follow-Up and Treatment Results in Thyroid Ophthalmopathy

Objectives:

To discuss our follow-up and treatment results in thyroid-associated ophthalmopathy (TAO).

Ma­te­ri­als and Met­hods:

The records of 168 TAO cases who were followed at our clinic between October 1998 and October 2013 were reviewed retrospectively. The severity and activity of the disease were evaluated according to the criteria of the European Group on Graves’ Ophthalmopathy (EUGOGO) and Clinical Activity Score (CAS).

Re­sults:

Sixty-three men and 105 women participated in the study. The mean age of the patients was 42.3±12.4 years. Smoking habit was noted in 54.2% of the cases. Graves’ disease was the most common (80.4%) thyroid pathology accompanying TAO. TAO was mild in 64.4%, moderate-to-severe in 33.6% and severe in 2% of the eyes. Male gender was found as an independent risk factor for severity of the disease (p=0.040). TAO was in the active phase in 32.6% of the eyes. Older age and high thyroid receptor antibody titer were correlated with disease activity (P=0.031 and P<0.001, respectively). Thirty-four patients (20%) were treated for ocular findings. The most common treatment was systemic steroid therapy (12%); others included orbital decompression (5%), orbital radiotherapy (2%), and topical application of guanethidine (1%).

Conclusion:

Non-infiltrative phase and mild ocular findings were generally seen in TAO. Therefore, treatment is not recommended for many cases. Systemic steroid therapy is the most commonly used treatment modality in the active phase. However, orbital decompression surgery is necessary in a small number of cases with sight-threatening ocular findings.

Prevalence, Phenotype, and Psychosocial Well-Being in Euthyroid/Hypothyroid Thyroid-Associated Orbitopathy

BACKGROUND

At the onset of thyroid-associated orbitopathy (TAO), most patients are hyperthyroid, while scarce data are available on euthyroid/hypothyroid TAO. The aim of this study was to assess the prevalence, phenotype, and psychosocial burden of patients with initially euthyroid/hypothyroid TAO.

METHODS

The medical records of 461 consecutive and unselected patients with TAO followed at a specialized joint thyroid-eye clinic were analyzed within this retrospective cross-sectional study. Main outcome measures were the prevalence of initially eu- or hypothyroid TAO as well as ophthalmic signs and symptoms, disease-specific quality of life (QoL), work impairment, and rate of psychotherapy in initially eu-/hypothyroid versus hyperthyroid TAO.

RESULTS

The prevalences of eu-/hypothyroid and hyperthyroid TAO were 4.3% (n=20; [confidence interval, CI, 2.6-6.3]) and 95.7% (n=441; [9.37-9.74]), respectively. In 12 patients (2.6% [CI 1.3-4.3]), Hashimoto's thyroiditis was present and in 8 (1.7% [CI 0.7-3.0]) no thyroid disease was noted at the time of inclusion. One (0.05%) patient with eu-/hypothyroid TAO and 172 (39%) with hyperthyroid TAO had clinically active TAO (p=0.001). In eu-/hypothyroid versus hyperthyroid patients, 14 (70%) versus 135 (30.6%) had a mild TAO, 6 (30%) versus 183 (64.2%) a moderate-to-severe TAO, and 0 versus 23 (5.4%) had a sight-threatening TAO (p<0.001). TAO was asymmetric in 4 (20%) eu-/hypothyroid and in 27 (6.1%) hyperthyroid patients (p=0.038). Only 5.3% versus 30.2% and 10.5% versus 44.1% of patients with eu-/hypothyroid and hyperthyroid TAO, respectively, were on sick leave (p=0.003) or work disabled (p=0.018). QoL was less impaired in eu-/hypothyroid versus hyperthyroid TAO (median visual functioning and appearance scores: 100 versus 75; p<0.001 and 81.25 versus 75; p=0.315). Of patients with eu-/hypothyroid and hyperthyroid TAO, 15% and 20.2% had psychotherapy respectively (p=0.409). Eu-/hypothyroid TAO was positively (odds ratio 7.05, p=0.060) and negatively (odds ratio: 0.09, p=0.026) associated with a unilateral involvement and thyrotropin-receptor autoantibodies respectively.

CONCLUSIONS

Compared with hyperthyroid TAO, QoL and working ability are less impaired in eu-/hypothyroid TAO with an often asymmetric and less severe clinical phenotype.

Thyroid eye disease: a Southeast Asian experience

AIM

To study the demographics, comorbidities, clinical manifestations and treatment methods of thyroid eye disease (TED) in Singapore.

METHODS

In this retrospective case series, we analysed the case records of all patients with TED who presented at our multidisciplinary Thyroid Eye Clinic from November 2002 to October 2012.

RESULTS

There were a total of 174 patients-111 female patients (63.8%) and 63 male patients (36.2%). The majority of the patients were ethnically Chinese (80.5%), followed by Malay (10.3%) and Indian (6.3%). The mean age was 40.2 years (SD±15.5, range 0.3-87.0). The commonest sign on ophthalmic examination was eyelid retraction (62.1%), followed by proptosis (61.0%) and lid lag (57.5). Acquired epiblepharon and corneal erosions were noted in 11.5% and 29.3% respectively. Eight patients (4.6%) had dysthyroid optic neuropathy. The mean exophthalmometry reading was 18.8 mm (SD±3.32, range 10.0-28.0). Mild, moderate and severe disease was noted in 71.3%, 20.7% and 8.0% respectively. Thyroid dysfunction was managed with anti-thyroid medication only (40.2%), β blockers (19.5%), thyroxine replacement (14.4%), radioactive iodine (14.4%) and block-replace regime (9.8%). Clinically significant active orbitopathy was managed with intravenous corticosteroids (12.1%). Surgical procedures consisted of thyroidectomy (10.3%), eyelid surgery (8.6%), orbital decompression (7.5%), epiblepharon correction (2.3%) and strabismus surgery (0.6%).

CONCLUSIONS

Corneal erosion secondary to acquired epiblepharon is a common sign in East Asian patients with TED, thus increased awareness among physicians should be encouraged. Mean exophthalmometry values and frequencies of upper eyelid retraction and oedema are lower in East Asian patients compared with Caucasian patients. Among Singapore's multi-ethnic population, Malay patients with TED had the highest exophthalmometry reading.

The relationship between sex and symmetry in thyroid eye disease

Purpose

To examine the relationships between sex and symmetry in the context of disease activity, severity, and thyroid status in thyroid eye disease.

Methods

Retrospective chart review of 31 men and 31 women with untreated thyroid eye disease. Subjective complaints, smoking status, thyroid status, and objective findings pertinent to the clinical activity score (CAS) and “NO SPECS” classification were recorded. Overall disease asymmetry was defined as having simultaneous asymmetry of both more than one symptom and more than one external finding. Asymmetry was compared across sex and thyroid status. CAS and NO SPECS severity were compared across sex, symmetry, and thyroid status.

Results

Asymmetric appearance was reported by 58% of men and 19% of women. Asymmetric proptosis (>2 mm difference) was seen in 45% of men and 23% of women (P=0.036). Overall asymmetry was seen in 55% of men and 19% of women (P=0.017). Thyroid status and sex had a combined effect on symmetry, as 15 of 16 hyperthyroid females (94%) demonstrated symmetric disease. Average NO SPECS severity was 3.5 (standard deviation [SD] 1.4) in men and 3.3 (SD 1.1) in women (P=0.51), and was 3.8 (SD 1.4) in asymmetric patients versus 3.2 (SD 1.3) in symmetric patients (P=0.08). The CAS was higher in asymmetric than symmetric patients (1.84 versus 0.97; P=0.012).

Conclusion

Men demonstrated more asymmetric disease (proptosis and overall asymmetry) than women, while hyperthyroid females demonstrated more symmetry than euthyroid and hypothyroid males and females. NO SPECS severity score was unaffected by sex, thyroid status, or symmetry. Asymmetric patients demonstrated higher clinical activity scores.

The influence of prior hyperthyroidism on euthyroid graves' ophthalmopathy

Background. To investigate the influence of previous exposure to elevated thyroid hormones in euthyroid Graves' ophthalmopathy. Design. Retrospective, observational case series in university setting Median follow-up of 1 year with ranges of 0,8-7,6 years. Study performance of 10 years. Participants. We reviewed the clinical records of 731 Graves' ophthalmopathy patients. There were 88 (12%) patients with onset of Graves' ophthalmopathy during euthyroidism: 37 (5%) patients had ophthalmopathy without known history of thyroid dysfunction (group A) and 51 patients (6%) had onset of ophthalmopathy 6 months or more euthyroid after completion of antithyroid therapy (group B). Main Outcome Measures. Graves' ophthalmopathy was graded using the EUGOGO severity criteria. Unilaterality was investigated. TSH receptor antibody and thyroid peroxidase antibody were measured as markers of Graves' disease. Results. Group A had more often a normal ocular motility (46%) and less proptosis (14 ± 4 mm) compared to group B (22%, 16 ± 4 mm) (P = 0.032 and 0.028, resp.). TSH receptor antibody was more frequently elevated in group B (94%) than in group A (17%) (P < 0.001). Conclusion. Patients with euthyroid Graves' ophthalmopathy present more often with ocular muscle restriction and proptosis when previously exposed to elevated thyroid hormones.

Current concepts in the molecular pathogenesis of thyroid-associated ophthalmopathy

Graves' disease (GD) is a common autoimmune condition. At its core, stimulatory autoantibodies are directed at the thyroid-stimulating hormone receptor (TSHR), resulting in dysregulated thyroid gland activity and growth. Closely associated with GD is the ocular condition known as thyroid-associated ophthalmopathy (TAO). The pathogenesis of TAO remains enigmatic as do the connections between the thyroid and orbit. This review highlights the putative molecular mechanisms involved in TAO and suggests how these insights provide future directions for identifying therapeutic targets. Genetic, epigenetic, and environmental factors have been suggested as contributory to the development of GD and TAO. Thyroid-stimulating hormone receptor and insulin-like growth factor receptor (IGF-1R) are expressed at higher levels in the orbital connective tissue from individuals with TAO than in healthy tissues. Together, they form a functional complex and appear to promote signaling relevant to GD and TAO. Orbital fibroblasts display an array of cell surface receptors and generate a host of inflammatory molecules that may participate in T and B cell infiltration. Recently, a population of orbital fibroblasts has been putatively traced to bone marrow-derived progenitor cells, known as fibrocytes, as they express CD45, CD34, CXCR4, collagen I, functional TSHR, and thyroglobulin (Tg). Fibrocytes become more numerous in GD and we believe traffic to the orbit in TAO. Numerous attempts at developing complete animal models of GD have been largely unsuccessful, because they lack fidelity with the ocular manifestations seen in TAO. Better understanding of the pathogenesis of TAO and development of improved animal models should greatly accelerate the identification of medical therapy for this vexing medical problem.

Graves' ophthalmopathy: epidemiology and natural history

Graves' ophthalmopathy (GO) is an autoimmune disorder of the orbit that is clinically relevant in 25-50% of patients with Graves' disease and 2% of patients with chronic thyroiditis. The age-adjusted annual incidence of clinically relevant GO is 16 per 100,000 population in women and 2.9 in men. At the onset of ophthalmopathy, 80-90% of patients have hyperthyroidism, with the rest having euthyroidism or hypothyroidism. The natural history of GO consists of two phases: an active inflammatory phase and a static phase. Anti-inflammatory therapy is indicated for the first phase of GO. Approximately 5% of patients experience late reactivation of GO. Asians appear to have less severe manifestations, with milder orbital edema, proptosis and muscle restriction. Genetic, anatomic and environmental factors influence the development of GO. Aging, thyroid dysfunction, thyroid stimulating hormone (TSH) receptor antibodies, smoking and radioiodine treatment for hyperthyroidism also influence the development and course of GO.

Unilateral proptosis in thyroid eye disease with subsequent contralateral involvement: retrospective follow-up study

Background

The purpose of this retrospective follow-up study is to evaluate the prevalence of patients with thyroid eye disease presenting with apparent unilateral proptosis and determine the occurrence of exophthalmos in contralateral non-proptotic eye over the time. Associated features with this event were evaluated.

Methods

A cohort of 655 consecutive patients affected by thyroid eye disease with a minimum follow-up of 10 years was reviewed. Exophthalmos was assessed by using both Hertel exophthalmometer and computed tomography (CT). The influence of age, gender, hormonal status and of different therapies such as corticosteroids, radiotherapy and surgical decompression on this disease progression was evaluated.

Results

A total of 89 patients (13.5%) (95% confidence interval [CI] 15%-10%) had clinical evidence of unilateral exophthalmos at the first visit. Among these, 13 patients (14%) (95% CI 22%-7%) developed subsequent contralateral exophthalmos. The increase of protrusion ranged from 2 to 7 mm (mean of 4.2). The time of onset varied from 6 months to 7 years (mean time: 29 months). Smoking status, young age and surgical decompression are significantly associated with development of contralateral proptosis (p< .05).

Conclusions

Asymmetric thyroid eye disease with the appearance of unilateral exophthalmos at the initial examination is a fairly frequent event, while subsequent contralateral proptosis occurs less commonly. However, physicians should be aware that young patients, particularly if smokers, undergoing orbital decompression in one eye may need further surgery on contralateral side over time.

Differential involvement of orbital fat and extraocular muscles in graves' ophthalmopathy

Graves' ophthalmopathy (GO) is characterized by swelling of orbital fat and extraocular muscles, but little attention has been given to differential involvement of fat and muscles. Advancements in imaging allow rather accurate measurements of orbital bony cavity volume (OV), fat volume (FV) and muscle volume (MV), and are the topics of this review. Ratios of FV/OV and MV/OV neutralize gender differences. In adult Caucasian controls, mean values ± SD of FV/OV are 0.56 ± 0.11 and of MV/OV are 0.15 ± 0.02. FV increases substantially and MV decreases slightly with advancing age, requiring age-specific reference ranges. In 95 consecutive untreated Caucasian GO patients, both FV and MV were within normal limits in 25%, increased FV but normal MV was present in 5%, normal FV but increased MV was detected in 61%, and both increased FV and MV was evident in 9%. Increased FV was associated with more proptosis and longer GO duration. Increased MV was associated with older age, more severe GO (more proptosis and diplopia, worse eye muscle ductions), higher TBII and current smoking. At the cellular and molecular level differential involvement of fat and muscles might be related to differences between fibroblast phenotypes and cytokine profiles in each compartment, to different orbital T cell subsets during the course of the disease and to peroxisome proliferator activator receptor-γ polymorphisms and modulation of 11β-hydroxysteroid dehydrogenase-1. Enlarged muscles are apparently a rather early phenomenon in GO, whereas increases in fat mass occur relatively late. Why a minor subset of GO patients presents with an increase of only fat remains poorly understood.

Imaging studies for diagnosing Graves' orbitopathy and dysthyroid optic neuropathy

Although the diagnosis of Graves' orbitopathy is primarily made clinically based on laboratory tests indicative of thyroid dysfunction and autoimmunity, imaging studies, such as computed tomography, magnetic resonance imaging, ultrasound and color Doppler imaging, play an important role both in the diagnosis and follow-up after clinical or surgical treatment of the disease. Imaging studies can be used to evaluate morphological abnormalities of the orbital structures during the diagnostic workup when a differential diagnosis versus other orbital diseases is needed. Imaging may also be useful to distinguish the inflammatory early stage from the inactive stage of the disease. Finally, imaging studies can be of great help in identifying patients prone to develop dysthyroid optic neuropathy and therefore enabling the timely diagnosis and treatment of the condition, avoiding permanent visual loss. In this paper, we review the imaging modalities that aid in the diagnosis and management of Graves' orbitopathy, with special emphasis on the diagnosis of optic nerve dysfunction in this condition.

Geriatric thyroidology: An update

Thyroid anatomy and physiology change in the elderly with age-related fibrosis and atrophy in the thyroid gland and changes in thyroid hormones. The incidence of thyroid nodules increases with age, making the thyroid more nodular. Hypothyroidism is common in the elderly and, if untreated, is associated with significant morbidity. Elderly patients are sensitive to iatrogenic hyperthyroidism, especially with preexisting cardiac disease. Hence, treatment of hypothyroidism should be individualized and should be started with low doses and titrated according to response. Hyperthyroidism, although less common in the elderly if present, is associated with significant cardiac morbidity and mortality. Radioiodine therapy is considered a safe primary treatment in the elderly with hyperthyroidism. Management of subclinical hypo- and hyperthyroidism is still controversial. The incidence of thyroid tumors increase with age. Thyroid malignancy in the elderly is considered as a more advanced disease compared with the young, and aggressive management is recommended.

Epidemiology of Graves' orbitopathy (GO) and relationship with thyroid disease

The incidence of Graves' orbitopathy (GO) is 16/100,000 in females and 2.9/100,000 in males as studied in Olmsted county. It can be calculated that the approximate prevalence is 0.25%. There is a gender bimodal distribution. Go usually occurs at the time of onset of the hyperthyroidism but may present up to a year before that time or as long as 5 years afterwards. Around 10-15% of patients have never been hyperthyroid and some are hypothyroid at GO presentation. Although the incidence of GO has probably been decreasing during the last 2 decades definite figures for this assertion are not available. Risk factors that may influence the incidence of GO include cigarette smoking and radioiodine treatment of hyperthyroidism. There are also complex genetic factors with multiple susceptibility alleles that contribute to the expression of the disease. The probability is that a reduction of the incidence of GO will be achieved by influencing the environmental factors.

Evaluating Graves' orbitopathy

Graves' Orbitopathy (GO) is an immune-mediated disorder causing inflammation and expansion of orbital fat and muscle. The resulting spectrum of ocular and orbital changes may cause significant visual and cosmetic morbidity and are graded as disease severity. The disease follows a biphasic course with an active or progressive phase followed by a quiescent or stable phase: the temporal status is graded as disease activity. Grading systems for GO include Werner's NO SPECS and European Group on Graves' Orbitopathy (EUGOGO)'s severity scales, the Clinical Activity Score (CAS) and the VISA Classification (for severity and activity). Diagnosis of GO is based on recognition of clinical features and may be supported by thyroid function and immune testing, and orbital imaging. The endocrinologist or internist may play an important role in early recognition and diagnosis of GO, in grading severity and activity, and in arranging appropriate referral to an ophthalmologist based on this evaluation.

Bilateral versus unilateral thyroid eye disease

Aims:

The aim of this study was to compare demographics, clinical manifestations, associated systemic and ocular factors, severity and activity of patients with unilateral thyroid eye disease (U-TED) versus bilateral thyroid eye disease (B-TED).

Materials and Methods:

In a cross-sectional study, all patients with Graves’ hyperthyroidism and primary hypothyroidism seen in an endocrinology clinic were included from September 2003 to July 2006. Demographics, complete eye examination, severity score (NOSPECS, total eye score), and clinical activity score were recorded and compared in the B-TED and U-TED groups of patients.

Results:

From 851 patients with thyroid disorders, 303 (35.6%) had TED. Thirty-two patients (32/ 303, 10.56%) were found to have U-TED. Patients with U-TED (mean age 31.6 ± 11.6 years) were significantly younger than patients with B-TED (mean age 37.7 ± 14.7 years). Monovariate analysis (Chi-square and independent sample t-test) showed a significantly higher severity score in B-TED (U-TED 4.09±4.05, B-TED: 6.7±6.3; P= 0.002) and more activity score in B-TED (U-TED= 1.03±0.96, B-TED: 1.74±1.6, P= 0.001). However, multivariate analysis did not show any significant difference between the two groups in terms of age, gender, type of thyroid disease, duration of thyroid disease and TED, severity and activity of TED, smoking habit, and presentation of TED before or after the presentation of thyroid disease (0.1<P<1).

Conclusion:

This study did not find any significant difference between U-TED and B-TED in relation to the demographics, type of thyroid disease, associated findings, and severity and activity of TED.

Acquired lower eyelid epiblepharon in thyroid-associated ophthalmopathy of Koreans

PURPOSE

To investigate the prevalence and clinical features of acquired lower eyelid epiblepharon in Korean patients with thyroid-associated ophthalmopathy (TAO) and compare the pathogenic features of acquired and congenital epiblepharon.

DESIGN

Retrospective, nonrandomized, comparative case series, cross-sectional study.

PARTICIPANTS

A total of 494 Korean patients with TAO and 845 Korean patients with congenital lower eyelid epiblepharon.

METHODS

The medical records were reviewed, and the presence, location, and extent of epiblepharon were identified. Clinical features of TAO (lower eyelid retraction, exophthalmos, and elevation limitation) were compared between patients with TAO with and without epiblepharon. Acquired epiblepharon was classified into 3 types according to the location and extent. The prevalence of epiblepharon types was determined and evaluated for associations with TAO clinical features. Comparisons were made between the prevalence of epiblepharon types in acquired and congenital epiblepharon.

MAIN OUTCOME MEASURES

Prevalence, location, and extent of epiblepharon; association with clinical features of TAO; and difference from congenital epiblepharon.

RESULTS

An acquired lower eyelid epiblepharon was found in 42 (8.5%) of 494 patients with TAO. The mean age of patients with TAO with epiblepharon (34.2±13.5 years) was significantly lower than that of patients with TAO without epiblepharon (46.5±14.1 years) (P = 0.000). Lower eyelid retraction (0.78±1.11 mm) was more severe in patients with TAO with epiblepharon than in patients without epiblepharon (0.30±0.73 mm) (P = 0.000). Lower eyelid retraction was more severe in diffuse-type acquired epiblepharon than in central-type epiblepharon (P = 0.012). Elevation limitation was more severe in central-type acquired epiblepharon than in medial-type epiblepharon (P = 0.001). The occurrence of central-type epiblepharon was higher in TAO-associated acquired epiblepharon (20 eyelids, 30.8%) than in congenital epiblepharon (27 eyelids, 1.9%, P = 0.000).

CONCLUSIONS

Acquired lower eyelid epiblepharon is one of the clinical features of patients with TAO. The association between lower eyelid retraction and acquired epiblepharon may lead to a better understanding of the cause of acquired epiblepharon in patients with TAO.

Hyperthyroid vs hypothyroid eye disease: the same severity and activity

PURPOSE

To compare demographics, severity, and activity of thyroid eye disease (TED) in patients with hyperthyroidism (Hr-TED) vs primary hypothyroidism (Ho-TED).

PATIENTS AND METHODS

In a cross-sectional study, demographics, complete eye examination, severity score (NOSPECS, total hundred eye score), clinical activity score, and Rundle grading were recorded for patients with TED and different thyroid disorders referred from an endocrinology clinic from 2003 to 2006.

RESULTS

TED was clinically found in 303 patients (303/851, 35.6%). The majority of them (280/303, 92.4%) had Graves' hyperthyroidism and 23 (23/303, 7.5%) had primary hypothyroidism. Mean age, gender, mean severity score, mean activity score, Rundle grade, unilateral presentation of TED, smoking habit, mean duration of eye disease, and mean interval time of thyroid to TED were not significantly different between the two groups (0.06<P<0.9). Mean duration of thyroid disease was significantly (P=0.02) longer in the Hr-TED group (49.6 months) than in the Ho-TED group (22.7 months). Most of the patients in both groups (63.2% of Hr-TED and 73.9% of Ho-TED) developed the eye disease within 18 months before or after the thyroid disease.

CONCLUSION

The same demographics, clinical characteristics, and severity and activity scores for Hr-TED and Ho-TED imply that both groups present the same category of eye disease.

Double motion of upper eyelids in Graves' orbitopathy: an additional sign for detection of thyroid dysfunction or positive thyroid autoantibodies

Purpose:

To assess the effectiveness of the upper eyelid double motion sign in Graves’ orbitopathy (GO) in detecting thyroid dysfunction or a positive level of thyroid-related autoantibodies.

Methods:

GO was defined when more than two GO-related eyelid symptoms, including the double motion sign, existed with at least one positive thyroid-related blood test. Blood tests were performed in patients with more than two GO-related eyelid symptoms. The double motion was defined when the upper eyelid stopped at least once during downward eye movement. Fifty patients without GO or other eyelid diseases were used as controls.

Results:

There were 353 patients who showed more than two GO-related eyelid symptoms including the upper eyelid double motion sign. Of these, 300 patients were diagnosed with GO (300/353, 85.0%). The double motion sign was demonstrated in 267 patients (75.6%). A pause in double motion was typically seen around the anterosuperior direction of gaze. Double motion was not seen in any of the control eyelids. Although only 7.0% were hyperthyroid and 8.6% were hypothyroid, thyroid related autoantibodies were shown in 73.9% of patients. When the double motion sign was removed from the diagnostic criteria of GO, 263 patients had more than two thyroid-related eyelid symptoms, including 223 patients diagnosed as GO (25.7% reduction), although the rate of a correct diagnosis was almost the same (84.8%).

Conclusions:

The double motion sign of the upper eyelids is frequently demonstrated in GO patients. This previously unreported sign can help in detecting thyroid dysfunction states with positive levels of autoantibodies.

Effect of smoking on orbital fat and muscle volume in Graves' orbitopathy

BACKGROUND

Smoking adversely affects the course and severity of Graves' orbitopathy (GO). Cigarette smoke enhances adipogenesis in cultured human orbital fibroblasts. The present study tested our hypothesis that smoking is associated with increased orbital fat in GO patients.

METHODS

This was an observational case series study. In 95 consecutive patients with untreated GO, the ratios of fat volume/orbital volume (FV/OV) and muscle volume/OV (MV/OV) were calculated with validated software. The most affected orbit of each patient was chosen for analysis. Patients were divided into two groups based on smoking behavior. One group was current smokers (Sm+) and the other were those who never smoked or those who had not smoked for at least 1 year (Sm-). Patients were grouped in tertiles of FV/OV and MV/OV and contrast in OVs between the Sm+ and Sm- group. The main characteristics of GO were analyzed using Jonckheere-Terpstra trend analysis and Mann-Whitney U-test.

RESULTS

The proportion of current smokers was not different in GO patients when divided in tertiles according to their FV/OV. In contrast, analysis of MV/OV tertiles showed a trend to a higher prevalence of current smokers in patients with larger MVs. Smoking did not influence FV, but the Sm+ group had significantly larger MVs than the Sm- group.

CONCLUSION

Smoking is associated with an increase in extraocular MV in untreated patients with GO and not with an increase in FV.

Sinus opacification associated with exacerbation of thyroid eye disease

PURPOSE

To describe the association of sinus opacification with exacerbation of thyroid eye disease. Three cases followed orbital decompression performed when disease was quiescent and one case occurred without prior orbital or sinus surgery.

DESIGN

Retrospective observational case series.

METHODS

Four patients' charts were retrospectively reviewed.

RESULTS

Three patients with thyroid eye disease (TED), whose ophthalmopathy was stable after orbital decompression surgery, experienced recurrence of TED signs and symptoms after development of sinus inflammation. The fourth patient with TED did not have orbital surgery but presented with unilateral ophthalmopathy and ipsilateral sinus opacification.

CONCLUSION

Paranasal sinus disease can exacerbate TED, possibly through a nonspecific inflammatory response. Minimizing inflammation proximal to the orbit may afford some protection against progression of the orbital process occurring in TED.

Risk factors for development or deterioration of Graves' ophthalmopathy

BACKGROUND

Graves' ophthalmopathy (GO) significantly impairs the quality of life of affected individuals and the most severe cases can be sight threatening. Given the limited therapeutic options, a strong emphasis should be placed on disease prevention to diminish the significant morbidity associated with this disease.

SUMMARY

GO is most prevalent in women and most severe in men. Although some genetic differences between GO patients and Graves' disease patients without ophthalmopathy have been identified, none of the polymorphisms identified to date impart a high enough risk of GO to justify genetic testing to guide therapy or preventive strategies. Poorly defined mechanical factors that appear also to play a role in GO susceptibility will likely be better elucidated with advances in imaging techniques. Tobacco smoking has been consistently linked to development or deterioration of GO. Smokers who receive radioactive iodine have the highest incidence of unfavorable GO outcome, which is proportional to the number of cigarettes smoked per day. Several studies have reported an association between radioactive iodine treatment for Graves' disease and worsening or development of GO. Observational studies suggest that the same appears to be true for thyroid dysfunction, including both hyper- and hypothyroidism. While thyrotropin receptor antibody levels appear to be useful in predicting the course of disease and response to therapy, it is not known whether they are predictive of GO development. The puzzling scenarios of euthyroid or clinically unilateral GO, the large number of nonsmoking GO patients, and the occasional development of GO years after thyroid dysfunction has been treated all underline the multifactorial etiology of this disorder in which no single factor determines the clinical outcome.

CONCLUSIONS

GO appears to have a complex genetic basis with multiple susceptibility alleles that act in combination with nongenetic factors to contribute to disease expression.

Transnasal endoscopic approach in the treatment of Graves ophthalmopathy: the value of a medial periorbital strip

OBJECTIVES

Present our experience with orbital decompression using an endoscopic transnasal approach and test whether preservation of an anteroposterior periorbital strip overlying the medial rectus muscle can reduce the incidence of postoperative diplopia.

PATIENT AND METHODS

Retrospective, descriptive study conducted on 16 patients with Graves ophthalmopathy operated on with orbital decompression between 2004 and 2009.

RESULTS

Twelve women and four men (mean age, 34.6 years), a total of 30 orbits, were operated. A medial periorbital strip along the medial rectus muscle was preserved in 13 patients. A single case (7.7%) presented postoperative diplopia. The mean reduction of proptosis was 4.3mm.

CONCLUSIONS

The endoscopic transnasal approach provides comparable results to those obtained with other techniques. The incidence of postoperative diplopia seems to decrease when an anteroposterior periorbital periosteal strip is preserved along the medial rectus muscle.

Radiotherapy in the treatment of Graves ophthalmopathy-to do it or not?

To the objective of this study is to evaluate the role and toxicity of radiotherapy in the treatment of Graves ophthalmopathy. In the years 2000-2003, 121 patients with malignant exophthalmos were treated with radiotherapy of the retrobulbar area to the total dose of 20 Gy in ten fractions with a 6 MeV photon beam. The treatment was performed by the team of the Clinic of Oncology of the Jagiellonian University Medical College in Cracow. The radiotherapy was preceded by intravenous steroid therapy: methylprednisolone acetate administered at the dose of 2 g/week for four consecutive weeks. The highest efficacy, expressed as improvement of all ocular symptoms, was observed for the combined treatment. Female and non-diabetic patients responded positively to the combined treatment. Radiotherapy combined with steroid therapy in the treatment of Graves ophthalmopathy seems to be an effective treatment for strictly defined indications. In the treatment of Graves-Basedow disease, radiotherapy is a well-tolerated treatment modality. Diabetes is a factor that worsens prognosis in Graves ophthalmopathy and female sex is a favourable factor for this condition.

Thyroid-associated orbitopathy: who and how to treat

Thyroid-associated orbitopathy is the most frequent and troublesome nonthyroidal complication of Graves' disease. It is mandatory to determine whether sight-threatening orbitopathy is present, as this requires prompt and aggressive treatment. Therapies for non-sight-threatening disease range from supportive measures only to medical therapies for active eye disease and surgical rehabilitation for burnt-out disease. Intravenous steroids and orbital radiotherapy are the mainstays of medical therapy. Rehabilitative surgery is frequently a staged process that may involve sequentially: orbital decompression, strabismus surgery, and eyelid procedures. Smoking cessation is recommended at all disease stages. Treatment within a multidisciplinary team consisting of both endocrinologists and ophthalmologists may lead to optimal patient outcomes.

Development and validation of a patient symptom questionnaire to facilitate early diagnosis of thyroid-associated orbitopathy in graves' disease

BACKGROUND

To construct a patient-based symptom questionnaire to facilitate early referral of thyroid-associated orbitopathy (TAO) in Graves' hyperthyroidism (GH).

METHODS

Phase I of our study involved developing a symptomatology-based questionnaire for the self-reporting of TAO symptoms in patients recently diagnosed with GH. Phase II involved administering the questionnaire along with a standard ophthalmic examination to a screening cohort of patients newly diagnosed with GH. Symptoms highly associated with the clinical diagnosis of TAO were used to construct a tool with the highest possible sensitivity. Phase III involved validation of this tool in a new cohort of patients recently diagnosed with GH. For each patient, the diagnosis of TAO was made by both a standardized orbital ophthalmic exam and the questionnaire. Results from the questionnaire were then compared to the clinical examination.

RESULTS

The questionnaire was compared to the standardized examination and found to have a sensitivity of 0.76 and a specificity of 0.82 in the validation phase of the study.

INTERPRETATION

This questionnaire may be a useful tool in clinical practice to allow identification of patients with TAO secondary to GH. Future studies using this questionnaire are needed to determine whether earlier identification and management of these patients is associated with reduced morbidity from TAO.