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

A 'Real Life' Service Evaluation Model for Multidisciplinary Thyroid Eye Services

BACKGROUND/AIMS

There is no universal consensus on the practical implementation and evaluation of the Amsterdam Declaration on Graves Orbitopathy in a Multidisciplinary Thyroid Eye Disease (MDTED) pathway. Recent recommendations from the UK TEAMeD-5 and BOPSS initiative highlight the importance of prevention, screening, and prompt referral of patients with moderate to severe and sight-threatening thyroid eye disease to multidisciplinary (MDTED) clinics and recommends annual auditing. We propose a practical service evaluation model with Key Performance Indicators (KPI) that are achievable and could be implemented across most TED pathways.

MATERIAL AND METHODS

We conducted a service evaluation from an integrated TED pathway in London with three MDTED clinics. Data was collected retrospectively from consecutive TED patients included: 1) Patient demographics, 2) Referral to first appointment time, 3) Documented smoking cessation and selenium supplementation advice, 4) Presenting disease activity and severity, 5) Investigations and treatments, including radio-iodine, 6) Time from decision to treatment initiation, 7) Initial and subsequent thyroid status.

RESULTS

The median age was 49.0 yrs, 77.5% (183/236) were female and 49.5% (101/204) Afro-Caribbean or Asian. At their first clinic attendance, 47.6% (110/231) were biochemically euthyroid and 76.7% (79/103) at discharge. All 23.1% (52/225) current smokers received smoking cessation advice and 64.8% (153/236) received selenium supplementation advice. Intravenous methylprednisolone was given to 33.9% (80/236) patients and 12.7% (30/236) received second-line immunosuppression. All 7.2% (17/236) patients with sight-threatening disease received treatment within two weeks of diagnosis.

CONCLUSIONS

This study forms a waymark for other units using TEAMeD-5 and BOPSS audit criteria. Dedicated electronic patient records with ongoing data capture, including quality of life assessments, and diagnostic coding would significantly aid future auditing, improve patient care, and facilitate a national audit of TED management. A future survey when the TED standards have become embedded would be instructive to see whether this has improved TED care.

Association of Other Autoimmune Diseases With Thyroid Eye Disease

BACKGROUND

Thyroid eye disease (TED) is a potentially disfiguring and sight-threatening autoimmune (AI) orbitopathy, affecting up to 400,000 people in the UK. There are no accurate early predictors of TED severity. Although polyautoimmunity has been shown to affect AI disease severity, its influence on TED severity has never been investigated. The prevalence of polyautoimmunity among TED patients is also unclear, with discordant results reported in the literature. This study evaluates the prevalence of non-thyroid/"other" AI (OAI) conditions in an ethnically diverse TED cohort and assesses how polyautoimmunity affects TED severity and activity.

METHODS

A retrospective study of patients presenting to multidisciplinary TED clinics across three North-West London hospitals between 2011 and 2019. Data collected included: 1) demographics; 2) OAI conditions and management; 3) endocrine management of thyroid dysfunction; 4) details of TED and clinical activity score at presentation.

RESULTS

Two hundred and sixty-seven patients with a median age of 46 (35-54) years were included, 79.4% were female and 55% were Black, Asian and minority ethnic (BAME). Thirty-seven patients (13.9%) had OAI conditions, with rheumatoid arthritis (3.7%), vitiligo (3.0%) and psoriasis (3.0%) among the most prevalent. Of patients with OAI conditions, 43.2% (16/37) required immunosuppression prior to TED onset. Non-immunosuppressed patients with OAI conditions had a significantly higher clinical activity score at presentation than TED-only and previously immunosuppressed patients (p=0.02). No significant differences were observed in thyroid receptor antibody titers between these groups.

CONCLUSIONS

This study finds a 13.9% prevalence of OAI conditions among TED patients. Patients with OAI conditions overall have a tendency for more severe and significantly more clinically active TED than those without OAI conditions. Larger, prospective studies are warranted to further evaluate polyautoimmunity as an early predictor of TED severity.

Updates on the understanding and management of thyroid eye disease

Thyroid eye disease (TED) is a complex disease associated with myriad clinical presentations, including facial disfigurement, vision loss, and decreased quality of life. Traditionally, steroid therapy and/or radiation therapy were commonly used in the treatment of active TED. While these therapies can help reduce inflammation, they often do not have a sustainable, significant long-term effect on disease outcomes, including proptosis and diplopia. Recent advances in our understanding of the pathophysiology of TED have shifted the focus of treatment toward targeted biologic therapies. Biologics have the advantage of precise immune modulation, which can have better safety profiles and greater efficacy compared to traditional approaches. For instance, the insulin-like growth factor-1 receptor (IGF-1R) has been found to be upregulated in TED patients and to colocalize with the thyroid-stimulating hormone receptor (TSHR), forming a signaling complex. Teprotumumab is an antibody targeted against IGF-1R. By inhibiting the IGF-1R/TSHR signaling pathway, teprotumumab may reduce the production of proinflammatory cytokines, hyaluronan secretion, and orbital fibroblast activation in patients with TED. Due to promising phase II and III clinical trial results, teprotumumab has become the first biologic US Food and Drug Administration (FDA)-approved for the treatment of TED. In addition, there are currently ongoing studies looking at the use of antibodies targeting the neonatal Fc receptor (FcRn) in various autoimmune diseases, including TED. FcRn functions to transport immunoglobulin G (IgG) and prevent their lysosomal degradation. By blocking the recycling of IgG, this approach may dampen the body's immune response, in particular the pathogenic IgG implicated in some autoimmune diseases. Advances in our understanding of the pathophysiology of TED, therefore, are leading to more targeted therapeutic options, and we are entering an exciting new phase in the management of TED. This review will cover recent insights into the understanding of TED pathophysiology and novel treatment options as well as ongoing studies of new potential treatment options for TED.

Gender differences in clinical presentation and prognosis of thyroid eye disease

OBJECTIVE

To examine the clinical differences in manifestation, treatment, and prognosis of thyroid-eye-disease (TED) between men and women.

METHODS

This is a longitudinal cohort study. Men and women, who diagnosed with TED and treated at a multidisciplinary TED clinic, were compared regarding differences in demographics, eye examination, disease activity, and quality of life evaluation.

RESULTS

TED was diagnosed in 132 patients during the study period, and they included 38 men (28.78%) and 94 women (71.21%). There were six men and 20 women with active disease (Clinical-Activity-Score (CAS) ⩾ 3) during the entire follow-up period (p < 0.01). The mean time from TED diagnosis to CAS ⩾ 3 was 4.50 years for men and 2.35 years for women (p = 0.05). There were no significant differences in mean total Graves' Orbitopathy-Quality-of-Life questionnaire (GO-QOL) score. However, mean GO-QOL subtotal score of external appearance of women was significantly lower compare to men in the first and last visit (p = 0.04, 0.03, respectively).

CONCLUSION

Active disease was more common in women and the time-from-diagnosis of TED to CAS ⩾ 3 was shorter among women. Moreover, the appearance QOL score of women was poorer. These findings should be taken into consideration when planning the timing of treatment and when choosing the best treatment for TED patients.

Clinical features and clinical course of thyroid-associated ophthalmopathy: a case series of 3620 Chinese cases

OBJECTIVES

To determine the clinical features and course of thyroid-associated ophthalmopathy (TAO) in a large sample of Chinese patients.

DESIGN AND METHODS

We retrospectively identified a cohort of consecutive patients diagnosed with TAO at the West China Hospital from October 1, 2009 to October 1, 2019. We analysed clinical data from 3620 patients, including demographic data, clinical manifestations, ophthalmology examinations, and prognosis.

RESULTS

TAO most frequently occurred with hyperthyroidism, with most patients developing TAO after thyroid disease (TD). The TAO phenotype was asymmetric in 375 (50.7%) euthyroid patients, 25 (27.8%) hypothyroid patients, and 314 (12.1%) hyperthyroid patients (p < 0.0001). The most frequent symptom was lid lag and the most commonly involved extraocular muscle was the inferior rectus. Severity assessment (NOSPECS score) and clinical activity assessment (Clinical Activity Scores, CAS) differed significantly between male and female patients (P < 0.000). The majority (88.8%) of patients had clinically inactive TAO, and only 3.2% of cases were sight-threatening. Regarding the clinical process, 75.5% of patients had an active phase time less than 12 months and 2.1% showed complete remission.

CONCLUSIONS

TAO most commonly develops in females and is closely related to hyperthyroidism. Euthyroid TAO often has an asymmetric clinical phenotype. CAS combined with magnetic resonance imaging can improve the detection of TAO. NOSPECS scores should be slightly refined regarding the criteria for corneal involvement. Clinical management of TAO should be individualized according to CAS or NOSPECS assessments and a multidisciplinary approach is paramount. A minority of patients showed complete remission.

Eye Conditions in Women

Changes in vision can have significant impact on health and quality of life. Differences between women and men have been identified in the incidence of several eye conditions. Some of these differences are a result of the greater longevity of women. However, the eye, like other organs, is susceptible to the impacts of inflammation and sex steroids. Conditions, such as thyroid eye disease, optic neuritis, and dry eye disease are related to autoimmune or inflammatory conditions and are, thus, more common among women. Idiopathic intracranial hypertension occurs disproportionately in women of childbearing age; the etiology of this condition appears to be related to both inflammatory and sex hormone fluctuations.

Epidemiology, Natural History, Risk Factors, and Prevention of Graves' Orbitopathy

GO is the most frequent extrathyroidal manifestation of Graves' disease, although it may rarely occur in euthyroid/hypothyroid patients with chronic autoimmune thyroiditis. It is a relatively infrequent disorder, and men tend to have more severe ocular involvement at an older age. The prevalence of GO is lower than in the past among patients with recent onset Graves' hyperthyroidism, and moderate-to-severe forms requiring aggressive treatments are no more than 5-6% of all cases of GO. After an initial inflammatory (active) phase and a phase of stabilization (plateau phase), GO tends to improve and eventually inactivates (inactive or burnt-out phase). Minimal-to-mild GO often remits spontaneously, but complete restitutio ad integrum almost never occurs when GO is more than mild. Several risk factors contribute to its development on a yet undefined genetic background. Cigarette smoking is the most important of them. Early diagnosis, control and removal of modifiable risk factors, early treatment of mild forms of GO may effectively limit the risk of progression to more severe forms, which have a profound and dramatic impact on the quality of life of affected individuals, and remain a therapeutic challenge, often requiring long-lasting and multiple medical and surgical therapies.

Decreased Expression of TIM-3 on Th17 Cells Associated with Ophthalmopathy in Patients with Graves' Disease

Purpose:

Thyroid-associated Ophthalmopathy (TAO) is one of the most common orbital immunological diseases in adults. CD4+ helper T (Th) cells play important roles in the pathogenesis of TAO. But the mechanisms regulating CD4+ T cell activity is unclear. This study examines T cell immunoglobulin domain and mucin domain 3 (TIM-3) expression in helper T cell type 1 (Th1), Th17, and regulatory T cells in sufferers of TAO.

Methods:

Participants were divided into 3 groups: patients with TAO, patients with Graves’ disease but without orbitopathy (GD), and healthy control patients (HC). Peripheral blood samples were collected for each patient in the designated group. Flow cytometry methods assessed the frequency of Th1 (CD4+IFN-γ+), Th17 (CD4+IL-17+), regulatory T cells (CD4+CD25hiCD127lo), and TIM-3 protein expression. Mean fluorescence intensity (MFI) measured the magnitude of TIM-3 expression and the percentage of TIM-3+ cells for each patient.

Results:

Compared to the GD group, TAO patients possessed higher frequencies of Th1 and Th17 cells in peripheral blood samples. The percentage of TIM-3+ Th1 and Th17 cells was significantly lower in the TAO patients than the GD group. Across all patients sampled, TIM-3+ cell percentage negatively correlated with Th1 cell frequency. Th1 and Th17 cells exhibited significantly decreased expression of TIM-3 in TAO patients compared to healthy controls. Regulatory T cells showed little TIM-3 expression and we observed no significant differences in frequency between groups.

Conclusion:

These results suggest a role for TIM-3 in the regulation of Th1 and Th17 cells and the pathogenesis of Graves’ ophthalmopathy.

2019 European Thyroid Association Guidelines on the Management of Thyroid Dysfunction following Immune Reconstitution Therapy

Thyroid dysfunction (TD) frequently occurs as an autoimmune complication of immune reconstitution therapy (IRT), especially in individuals with multiple sclerosis treated with alemtuzumab, a pan-lymphocyte depleting drug with subsequent recovery of immune cell numbers. Less frequently, TD is triggered by highly active antiretroviral therapy (HAART) in patients infected with human immunodeficiency virus (HIV), or patients undergoing bone-marrow/hematopoietic-stem-cell transplantation (BMT/HSCT). In both alemtuzumab-induced TD and HIV/HAART patients, the commonest disorder is Graves' disease (GD), followed by hypothyroidism and thyroiditis; Graves' orbitopathy is observed in some GD patients. On the contrary, GD is rare post-BMT/HSCT, where hypothyroidism predominates probably as a consequence of the associated radiation damage. In alemtuzumab-induced TD, the autoantibodies against the thyrotropin receptor (TRAb) play a major role, and 2 main aspects distinguish this condition from the spontaneous form: (1) up to 20% of GD cases exhibit a fluctuating course, with alternating phases of hyper- and hypothyroidism, due to the coexistence of TRAb with stimulating and blocking function; (2) TRAb are also positive in about 70% of hypothyroid patients, with blocking TRAb responsible for nearly half of the cases. The present guidelines will provide up-to-date recommendations and suggestions dedicated to all phases of IRT-induced TD: (1) screening before IRT (recommendations 1-3); (2) monitoring during/after IRT (recommendations 4-7); (3) management of TD post-IRT (recommendations 8-17). The clinical management of IRT-induced TD, and in particular GD, can be challenging. In these guidelines, we propose a summary algorithm which has particular utility for nonspecialist physicians and which is tailored toward management of alemtuzumab-induced TD. However, we recommend prompt referral to specialist endocrinology services following diagnosis of any IRT-induced TD diagnosis, and in particular for pregnant women and those considering pregnancy.

Outcomes of endoscopic orbital decompression for graves' ophthalmopathy

BACKGROUND/AIMS

We assess outcomes of endoscopic orbital decompression for Graves' ophthalmopathy.

METHODS

A review of endoscopic orbital decompressions of the medial and partial inferior wall between July 2004 and July 2017 was carried out. Outcome was assessed by comparing pre- and post-operative measurements of exophthalmometry and visual acuity. Results were evaluated by repeated measures analysis of variance.

RESULTS

A total of 41 orbits in 25 patients underwent endoscopic orbital decompression for Graves' ophthalmopathy in the time period; however, six orbits in three patients had insufficient data for inclusion. Eleven patients required concurrent septoplasty to allow access. Measurements were taken at a mean of 11 days, 32 days, and 95 days post-operatively. Reduction in mean proptosis was 2.81 mm at 1-month post-decompression and 3.26 mm at 3 months. There was no significant difference between those treated for compressive optic neuropathy compared with those treated for cosmetic reasons. Colour vision by Ishihara plate improved significantly by a mean score of 2.67 post-operatively. Using LogMAR conversion for visual acuity, measured by a best-corrected Snellen chart, improvement of 0.18 was achieved at 1-month post-decompression, equivalent to approximately two lines on the Snellen chart. There was minimal (0.04) further improvement at 3 months. The improvement in visual acuity was greater in cases treated for compressive optic neuropathy than cosmesis, but this did not reach statistical significance (p = 0.06). Three cases required revision surgery. Diplopia disimproved or developed in four cases and squint surgery was required in three cases.

CONCLUSIONS

Endoscopic orbital decompression offers an effective, safe and minimally invasive treatment for Graves' ophthalmopathy. There is a trend towards continued improvement in outcomes over the course of 3 months post-operatively.

Evaluation of the Graves' Orbitopathy-Specific Quality of Life Questionnaire in the Mainland Chinese Population

Purpose

To study the clinical significance of the Graves' orbitopathy-specific quality of life (GO-QOL) questionnaire in mainland Chinese patients.

Methods

A cross-sectional study was performed at the Ophthalmology Department of the Sun Yat-sen Memorial Hospital from April 2017 to April 2018. Eighty-eight consecutive Graves' orbitopathy (GO) patients completed the two subscales of the GO-QOL questionnaire: visual functioning and appearance. The disease severity of GO was measured by the European Group on Graves' Orbitopathy (EUGOGO) classification, and clinical activity was evaluated by the clinical activity score (CAS).

Results

The mean scores of GO-QOL questionnaire for the visual functioning and appearance subscales were 68.4 ± 31.2 and 62.0 ± 27.4, respectively. Lower QOL scores for the visual functioning subscale were significantly correlated with disease severity, the CAS and diplopia (all p < 0.05). Lower QOL scores for appearance were significantly correlated with the CAS (p < 0.05). Although no correlation was found between the appearance subscale scores and disease severity (p=0.407), a downward trend in the appearance subscale scores as the severity of GO increased from mild to sight-threatening GO was found.

Conclusion

A strong correlation between disease severity and clinical activity has been shown in the GO-QOL questionnaire, suggested by the EUGOGO. The GO-QOL questionnaire is a simple and effective appraisal instrument in the evaluation of health-related QOL in the mainland Chinese patients with GO.

Association of anthropometric markers with globe position: A population-based MRI study

Purpose

Exophthalmometry is a common examination in ophthalmology. For example it is relevant for diagnosis or follow-up of thyroid eye disease. However, exophthalmometry is affected by several factors such as ethnicity, sex and age. The purpose of this study was to determine the globe position by magnetic resonance imaging (MRI) and to investigate its correlates among the general Northeast German adult population.

Methods

A total of 3030 subjects aged between 20 and 89 from the population-based Study of Health in Pomerania (SHIP) underwent a standardised whole-body MRI. Axial length and globe position were determined in axial T1-weighted images of the orbit. The image had to include the corneal apex as well as the optic nerve head. Study participants were excluded from imaging analysis if there was no plane available that included both structures. Further exclusion criterion was a lateral deviation of the subject’s viewing direction. Images with inadequate quality due to motion artefacts or other technical reasons were excluded as well. Globe position was defined as the perpendicular distance between the interzygomatic line and the posterior surface of the cornea (exophthalmometric value). The distance between the posterior surface of the cornea and the posterior pole of the eyeball, at the boundary with orbital fat, was defined as axial length. We used posterior surface of the cornea for our measurements, because it seemed to be less vulnerable for motion artefacts than the anterior one. Moreover body measurements including body mass index (BMI), waist and hip circumferences were determined. Associations between anthropometric measurements with exophthalmometric outcomes were analysed by linear regressions adjusted for age and stratified by sex. P-values <0.05 were considered as statistically significant. To assess intra-reader variability intra-class correlation coefficients (ICC) were computed for repeated measurements of the MRI scans of 25 subjects.

Results

After considering the exclusion criteria 1926 evaluable subjects remained. There was no significant difference between means of right and left eyes. The mean exophthalmometric value was significantly higher in men (16.5 +/- 2.2 mm) than in women (15.3 +/- 2.1 mm). The mean MRI-axial length was 23.4 +/- 0.8 mm for men and 22.8 +/- 0.9 mm for women. BMI, waist and hip circumferences were positively correlated with exophthalmometric value (p<0.001). Difference of mean MRI-based exophthalmometric value for obese subjects (BMI ≥30 kg/m²) and non-overweight (BMI <25 kg/m²) was 2.1 mm for men and 1.6 mm for women. ICC between 0.97 and 0.99 indicate excellent repeatability of our method.

Conclusion

We conclude that MRI-based exophthalmometric values are positively correlated with BMI, waist- and hip-circumference among the general Northeast German adult population. This association is independent from age and axial length. Consequently bodyweight of patients should be regarded to interpret exophthalmometric values correctly. MRI-exophthalmometry seems to be a suitable method to determine globe position. Considering the large number of study participants, exophthalmometric values of our study could be used as comparative values for exophthalmometry of people of Western European descent in future.

Role of Selenium Intake for Risk and Development of Hyperthyroidism

PURPOSE

To investigate the importance of dietary selenium (Se) for hyperthyroidism.

METHODS

We performed a more in-depth analysis of a large cross-sectional study of 6152 participants from two counties within the Shaanxi Province, China. These counties are characterized by different habitual Se intake. We investigated the effects of a different dietary Se supply (0.02, 0.18, 0.6, or 2.0 ppm Se) on disease development in a mouse model of Graves disease (GD).

RESULTS

The cross-sectional study revealed a comparable prevalence of hyperthyroidism, irrespective of Se intake, in both counties. However, an unexpected sex-specific difference was noted, and Se deficiency might constitute a risk factor for hyperthyroidism, especially in males. In a mouse model, pathological thyroid morphology was affected, and greater Se intake exerted some protecting effects on the pathological distortion. Circulating thyroid hormone levels, malondialdehyde concentrations, total antioxidant capacity, and the titer of GD-causing TSH receptor autoantibodies were not affected by Se. Expression analysis of the transcripts in the spleen indicated regulatory effects on genes implicated in the immune response, erythropoiesis, and oxygen status. However, the humoral immune response, including the CD4/CD8 or T-helper 1/T-helper 2 cell ratio and the concentration of regulatory T cells, was similar between the experimental groups, despite the difference in Se intake.

CONCLUSIONS

Our data have highlighted a sexual dimorphism for the interaction of Se and thyroid disease risk in humans, with indications of a local protective effects of Se on thyroid gland integrity, which appears not to be reflected in the circulating biomarkers tested.

Tumor necrosis factor-like weak inducer of apoptosis induces inflammation in Graves' orbital fibroblasts

Tumor necrosis factor-like weak inducer of apoptosis (TWEAK), along with its receptor fibroblast growth factor-inducible (Fn)14, is associated with various biological activities including inflammation. However, its role in the pathogenesis of Graves’ orbitopathy (GO) is unknown. In this study, we investigated the mechanism by which TWEAK regulates inflammatory signaling in orbital fibroblasts from GO patients. We found that TWEAK and tumor necrosis factor-α (TNFA) mRNA levels were upregulated in GO as compared to non-GO tissue samples. TWEAK, TNF receptor (TNFR)1, TNFR2, and TNFR superfamily member 12A mRNA, and TWEAK and Fn14 protein levels were increased by interleukin (IL)-1β and TNF-α treatment. Treatment with exogenous recombinant TWEAK increased the transcript and protein expression of the pro-inflammatory cytokines IL-6, IL-8, and monocyte chemoattractant protein-1 to a greater extent in GO than in non-GO cells, while treatment with the anti-Fn14 antibody ITEM4 suppressed TWEAK-induced pro-inflammatory cytokine release and hyaluronan production. Additionally, the serum level of TWEAK was higher in Graves’ disease patients with (341.86 ± 86.3 pg/ml) as compared to those without (294.09 ± 41.44 pg/ml) GO and healthy subjects (255.33 ± 39.38 pg/ml), and was positively correlated with clinical activity score (r = 0.629, P < 0.001) and thyroid binding immunoglobulin level (r = 0.659, P < 0.001). These results demonstrate that TWEAK/Fn14 signaling contributes to GO pathogenesis. Moreover, serum TWEAK level is a potential diagnostic biomarker for inflammatory GO, and modulating TWEAK activity may be an effective therapeutic strategy for suppressing inflammation and tissue remodeling in GO.

Correlation between thyroidal and peripheral blood total T cells, CD8+ T cells, and CD8+ T- regulatory cells and T-cell reactivity to calsequestrin and collagen XIII in patients with Graves' ophthalmopathy

Purpose/aim of the study: Graves' ophthalmopathy (GO) is closely related to the thyroid autoimmune disorder Graves' disease. Previous studies have suggested roles for thyroidal CD8⁺ T cells and autoimmunity against calsequestrin-1 (CASQ)-1 in the link between thyroidal and orbital autoimmune reactions in GO. A role for autoimmunity against CollXIII has also been suggested. In this study, we aimed to investigate correlations between some thyroidal and peripheral blood T-cell subsets and thyroidal T-cell reactivity against CASQ1 and CollXIII in patients with GO.

MATERIALS AND METHODS

Fresh thyroid tissues were processed by enzyme digestion and density gradient to isolate mononuclear cells (MNCs). Peripheral blood MNCs were also isolated using density gradient. Flow-cytometric analysis was used to identify the various T-cell subsets. T -cell reactivity to CASQ1 and CollXIII was measured by a 5-day culture of the MNCs and BrdU uptake method.

RESULTS

We found a positive correlation between thyroidal CD8⁺  T cells and CD8⁺ T-regulatory (T-reg) cells in patients with GO. Thyroidal T cells from two out of the three patients with GO tested (66.7%) showed a positive response to CASQ1, while thyroidal T cells from none of the six Graves' Disease patients without ophthalmopathy (GD) tested showed a positive response to this antigen. Thyroidal T cells from these patient groups however, showed no significant differences in their response to CollXIII.

CONCLUSIONS

Our observations provide further evidence for a possible role of thyroidal CD8⁺ T cells, CD8⁺ T-reg cells and the autoantigen CASQ1 in the link between thyroidal and orbital autoimmune reactions of GO.

Thyroid eye disease: what is new to know?

PURPOSE OF REVIEW

The pathophysiology of thyroid eye disease (TED) is still not fully understood. However, recently described risk factors and molecular findings have brought new insights into the mechanisms of TED and could lead to the emerging use of more targeted therapies. This article aims to review the clinical findings of TED, and the most recent advances in our understanding of the risk factors and therapeutic options for TED.

RECENT FINDINGS

Smoking has been recently shown to have an impact on specific gene expression involved in several disease-related pathways, which seems to be reversible with smoking cessation. This finding further emphasizes the importance of smoking cessation in the prevention and treatment of TED. Selenium deficiency and high-serum cholesterol have been described to be potential independent risk factors for TED and their management could decrease the incidence and severity of TED. In terms of therapeutic options, immunomodulatory medications have shown some promising results for disease control in TED over the past years, but further randomized prospective studies with larger sample sizes are still needed to prove their efficacy. A new technique of P brachytherapy was shown to have quick therapeutic effects on TED without significant side effects and could be a promising therapy for selected cases of TED.

SUMMARY

TED is one of the most common autoimmune inflammatory disorders of the orbit. Although its pathophysiology remains unclear, newly described genetic findings and risk factors could help in explaining its occurrence and guide future therapies. Immunosuppressant medications are increasingly used in the management of TED, but further studies are needed to confirm their effectiveness.

Combining micro-RNA and protein sequencing to detect robust biomarkers for Graves' disease and orbitopathy

Graves’ Disease (GD) is an autoimmune condition in which thyroid-stimulating antibodies (TRAB) mimic thyroid-stimulating hormone function causing hyperthyroidism. 5% of GD patients develop inflammatory Graves’ orbitopathy (GO) characterized by proptosis and attendant sight problems. A major challenge is to identify which GD patients are most likely to develop GO and has relied on TRAB measurement. We screened sera/plasma from 14 GD, 19 GO and 13 healthy controls using high-throughput proteomics and miRNA sequencing (Illumina’s HiSeq2000 and Agilent-6550 Funnel quadrupole-time-of-flight mass spectrometry) to identify potential biomarkers for diagnosis or prognosis evaluation. Euclidean distances and differential expression (DE) based on miRNA and protein quantification were analysed by multidimensional scaling (MDS) and multinomial regression respectively. We detected 3025 miRNAs and 1886 proteins and MDS revealed good separation of the 3 groups. Biomarkers were identified by combined DE and Lasso-penalized predictive models; accuracy of predictions was 0.86 (±0:18), and 5 miRNA and 20 proteins were found including Zonulin, Alpha-2 macroglobulin, Beta-2 glycoprotein 1 and Fibronectin. Functional analysis identified relevant metabolic pathways, including hippo signaling, bacterial invasion of epithelial cells and mRNA surveillance. Proteomic and miRNA analyses, combined with robust bioinformatics, identified circulating biomarkers applicable to diagnose GD, predict GO disease status and optimize patient management.

Low-Dose Rituximab for Active Moderate to Severe Graves' Orbitopathy Resistant to Conventional Treatment

Purpose: To report low-dose rituximab effect in Graves' orbitopathy (GO) resistant to conventional treatment. Methods: Retrospective analysis of medical records, filled in according to the European Group on Graves' Orbitopathy (EUGOGO) standards, of patients with active moderate-to-severe GO who received low-dose rituximab after failure of conventional treatment. Efficacy was defined by a decrease of the clinical activity score of 2 points or <4/10. Results: Among 219 patients treated between 2012 and 2016 by pulse methylprednisolone, possibly followed by oral steroids and/or orbital radiotherapy, 15 (6.8%) finally received 100 mg rituximab doses (cumulative dose, 100-400 mg) owing to persistent active disease. Rituximab showed efficacy within 2 months in 13 of 15 (87%), stable at 1 year. No significant effect was observed on proptosis, lid fissure width, and eye motility. Conclusion: Low-dose rituximab showed sustained anti-inflammatory effect in most patients with active GO resistant to conventional treatment.

Epidemiology and Clinical Features of Thyroid-associated Orbitopathy in Accra

PURPOSE:

Thyroid-associated orbitopathy (TAO), a clinical manifestation of Graves' disease, is an autoimmune disorder of the orbital and periorbital tissue. Data on the epidemiology and clinical presentation of TAO in Africa are generally scarce and unavailable in Ghana. We investigated the epidemiology and clinical features of TAO among patients with thyroid disorders attending the Korle Bu Teaching Hospital, Accra.

SUBJECTS AND METHODS:

This was a descriptive cross-sectional study of patients diagnosed with thyroid disorders which was conducted at the endocrine and orbital clinics of the Korle Bu Teaching Hospital. Diagnosis was based on clinical features and confirmed by a thyroid function test. Data collected and analyzed included demography, systemic and ocular features of thyroid disorder, and thyroid function tests.

RESULTS:

Of the 194 patients with thyroid disorders recruited, 117 (60.30%) had TAO. The mean age was 45.22 years (standard deviation: 13.90). The male:female ratio was 1:4.45. The most common ocular symptoms were “bulging eyes” (76/65.00%) and “puffy eyelid” (62/53.00%), and the common signs were eyelid retraction (97/82.91%) and proptosis (80/68.38%). Mild TAO was diagnosed in 64.96% of patients with only 6.84% having the severe form. The outcomes of the thyroid function test, thyroid disorder, and severity of TAO did not record any statistically significant differences.

CONCLUSIONS:

The epidemiology is similar to those reported from other parts of the world, but the ocular presentation seems to be milder than in Caucasians.

Role of methotrexate in thyroid-related orbitopathy

OBJECTIVE

To report the experience of a tertiary care orbital service in treating severe active thyroid related orbitopathy with methotrexate (MTX) managed by the Ophthalmologist.

DESIGN

Retrospective consecutive case series.

PARTICIPANTS

Nineteen consecutive patients (5 males and 14 females) with severe active thyroid related orbitopathy.

METHODS

Severe active thyroid orbitopathy patients with partial or no response to intravenous glucocorticoids were treated with MTX and observed for inflammatory scale reduction and treatment complications.

RESULTS

Nineteen consecutive patients (5 males and 14 females) with severe active thyroid related orbitopathy were evaluated. Mean follow-up time was 1206 days (standard deviation (SD) 576). Months passed from beginning of TRO symptoms to initiation of MTX therapy showed a mean of 12 (SD 9). After the initiation of MTX 91% of eyes demonstrated a clinically significant improvement to a VISA inflammatory scale of <3 within a mean of 189 days (SD 119); A subset of patients (29%) demonstrated a rapid response, reaching a VISA inflammatory score of <3 within 90 days. One patient (5%) discontinued the medication secondary to an adverse event (elevated liver enzymes) which normalized after discontinuation of MTX. During the follow up period 12 patients (63%) have ended their MTX treatment due to TRO inactivity; One patient (8%) developed a recurrence of inflammation after discontinuing MTX which resolved with the re-initiation of MTX treatment. Adjunctive treatments including glucocorticoids and/or external beam radiotherapy were administered to 21% of patients.

CONCLUSION

Our experience suggests that methotrexate managed by an Ophthalmologist is a safe and effective treatment for severe active thyroid related orbitopathy.

Changes in Choroidal Perfusion after Orbital Decompression Surgery for Graves' Ophthalmopathy

Purpose:

To assess choroidal perfusion before and after orbital decompression surgery in patients with Graves' ophthalmopathy.

Methods:

In this interventional case series, surgical decompression for optic nerve compromise was performed on four eyes of three patients with Graves' disease. Complete ophthalmic examination including visual acuity, color vision, and intraocular pressure assessment were done pre- and postoperatively. High-speed indocyanine green angiography was performed prior to surgery and was repeated one year after surgery.

Results:

In all three patients, choroidal perfusion defects were noted pre-operatively in the eyes with the compressive optic neuropathy. At 1 year after orbital decompression surgery, the defects improved or completely resolved. Improved visual acuity and color perception, as well as decreased intraocular pressure, were also noted postoperatively.

Conclusion:

Patients with Graves' orbitopathy may have abnormal choroidal perfusion even in the absence of optic neuropathy. Orbital decompression may improve choroidal circulation in these patients.

The effect of orbital radiation therapy on thyroid-associated orbitopathy complicated with dysthyroid optic neuropathy

Thyroid-associated orbitopathy (TAO) is an inflammatory autoimmune disorder. The most serious complication of TAO is dysthyroid optic neuropathy (DON), which can lead to permanent vision loss because of volume expansion in the orbital apex. Orbital radiation therapy (ORT) is an anti-inflammatory treatment used in the treatment of active TAO. Clinical studies support radiotherapy as having a modest effect on DON, and early radiotherapy may protect against disease progression to DON. Current studies suggest that radiotherapy is generally safe. However, risks still exist in some cases. The possible effects of radiotherapy on TAO, especially complicated with DON, are reviewed. The effects of radiotherapy on DON are not completely known, and evidence from standardized, prospective, and multicenter clinical trials is still lacking.

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.

Management of thyroid eye disease in the United Kingdom: A multi-centre thyroid eye disease audit

This article aims to provide baseline data and highlight any major deficiencies in the current level of care provided for adult patients with thyroid eye disease (TED). We undertook a prospective, nonrandomized cross-sectional multicenter observational study. During a 3-month period June-August 2014, consecutive adult patients with TED who presented to nominated specialist eye clinics in the United Kingdom, completed a standardized questionnaire. Main outcome measures were: demographics, time from diagnosis to referral to tertiary centre, time from referral to review in specialist eye clinic, management of thyroid dysfunction, radioiodine and provision of steroid prophylaxis, smoking, and TED classification. 91 patients (mean age 47.88 years) were included. Female-to-male ratio was 6:1. Mean time since first symptoms of TED = 27.92 (73.71) months; from first visit to any doctor with symptoms to diagnosis = 9.37 (26.03) months; from hyperthyroidism diagnosis to euthyroidism 12.45 (16.81) months. First, 13% had received radioiodine. All those with active TED received prophylactic steroids. Seven patients who received radioiodine and did not have TED at the time went on to develop it. Then, 60% patients were current or ex-smokers. 63% current smokers had been offered smoking cessation advice. 65% patients had active TED; 4% had sight-threatening TED. A large proportion of patients (54%) were unaware of their thyroid status. Not enough patients are being provided with smoking cessation advice and information on the impact of smoking on TED and control of thyroid function.

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.

THYROID HEMIAGENESIS ASSOCIATED WITH GRAVES' DISEASE: A CASE REPORT AND REVIEW OF THE LITERATURE

Introduction

Thyroid hemiagenesis (TH) is a congenital developmental disorder. Most cases are euthyroid although hyperthyroidism, hypothyroidism, and malignancy may develop. We present a case of hemiagenesis with Graves' disease (GD) and review the literature about the association.

Case report

A 45-year-old female patient was admitted to the endocrinology department due to nausea and diarrhea. Her past medical history revealed hyperthyroidism diagnosed a year ago. On thyroid examination, right thyroid lobe was palpable, but left lobe and isthmus were not. Physical examination involving other organ systems was unremarkable except for fine tremor of the hands. Thyroid function tests revealed a high level of free T4 and T3 with a low serum TSH. Thyroid antibodies were all positive. Left lobe and isthmus were invisible on thyroid ultrasonography (US) and the right thyroid lobe measuring 44x18x12 mm was diffusely heterogeneous in echo texture. Thyroid scan using Technetium-99m showed increased homogeneous tracer uptake in the right lobe. The patient was diagnosed with TH and GD.

Discussion

In case of unilateral increased uptake on scintiscan, GD with hemiagenesis must be kept in mind in the differential diagnosis of autonomous solitary adenoma, postinflammatory atrophy of thyroid in Hashimoto's disease, focal or unilateral subacute thyroiditis, and primary or metastatic carcinoma. It is prudent to do thyroid ultrasound along with scintigram. US is a valuable tool for the quick diagnosis of TH and differential diagnosis from other causes.

Socioeconomic Disparities in the Presentation and Treatment of Graves' Disease and Thyroid Eye Disease

Thyroid eye disease (TED) is an inflammatory, autoimmune orbitopathy with multifactorial etiology. Clinical presentation of TED spans a range from mild surface irritation to vision threatening compressive optic neuropathy. Potential vision loss underscores the importance of understanding genetic and environmental factors influencing the severity of TED presentation. This review will describe the classic risk factors for TED, outline treatments for Graves' disease (GD) and TED, and describe newer evidence of socioeconomic disparities in TED presentation.

Advances in the pharmacological treatment of Graves' orbitopathy

Graves' orbitopathy has a deteriorating effect on patients' appearance and vision, thus significantly decreases their quality of life. A multidisciplinary team of endocrinologists, ophthalmologists, head and neck surgeons, nuclear medicine physicians, radiologists, and psychologists should constitute a standard health care team for those patients. It is vital that the therapy is based on an individual approach, with patients being well informed and involved in the decision-making process. Generally, traditional therapies include immunosuppression with steroids, orbital irradiation and surgical decompression. Novel treatment modalities include: biological agents, somatostatin analogs, antioxidants, methotrexate. Better insight into pathogenesis of Graves' orbitopathy is the only chance for targeted therapy development.

Outcome of Radioiodine Therapy in a West African Population

Hyperthyroidism continues to be a pressing public health concern in West Africa. Its prevalence in Africa has been quoted as 1.2%-9.9%, with Graves' disease as its most common cause. Radioiodine-131 (RAI) therapy of hyperthyroidism recently commenced in two government hospitals in Ghana and Nigeria. This is a retrospective analysis of consecutive patients treated with RAI for primary hyperthyroidism at the National Centre for Radiotherapy and Nuclear Medicine (NCRNM) from 2008-2013, and in the University College Hospital (UCH) from 2006-2013. Cure was defined as euthyroidism or hypothyroidism occurring at 6 months post-RAI. Data were analysed using SPSS version 21 and Epi Info version, categorical data were evaluated with the Chi-square test and Fisher's exact test. 94 patients were studied, aged 20-74 years; 78 were females, and 16 were males. 38 were Ghanaian and 56 Nigerian. The presence of thyroid-associated ophthalmopathy (TAO) made cure less likely (χ(2) P = 0.006, odds ratio = 0.118; 95% confidence interval, 0.027-0.518). Other factors assessed proved to be insignificant. Our findings suggest that hyperthyroid patients with TAO will benefit from a higher RAI dose than their counterparts without TAO.

Serum concentrations of HGF and IL-8 in patients with active Graves' orbitopathy before and after methylprednisolone therapy

INTRODUCTION

Graves' disease is the most common cause of hyperthyroidism, and orbitopathy is the most frequent extrathyroidal manifestation of Graves' disease. The aims of this study were as follows: (1) to evaluate the serum concentration of HGF and IL-8 in the blood of newly diagnosed Graves' disease patients with the first episode of active GO and healthy controls; (2) to estimate the influence of the thyroid function (euthyreosis vs. hyperthyreosis) on HGF and IL-8 blood levels in patients with active GO; (3) to evaluate the influence of intravenous (i.v.) methylprednisolone (MP) pulse therapy and additional oral MP treatment on HGF and IL-8 blood levels in patients with active GO.

PATIENTS AND METHODS

Thirty-nine Graves' disease patients with the first episode of clinically active GO (Group A) were enrolled in the study. To estimate the influence of the thyroid function on serum concentrations of the studied proangiogenic factors, Group A was divided into Group A I (n = 18) in euthyroid and Group A II (n = 21) in hyperthyroid stage of Graves' disease in moderate-to-severe stage of GO. The control group consisted of 20 healthy volunteers age- and sex-matched to the GO group. Concentrations of the studied proangiogenic factors in serum samples were measured by an enzyme-linked immunosorbent assay before (Group A) and after (Group A1) intensive pulse i.v.MP treatment and 1 month after the end of additional oral MP treatment (Group A2).

RESULTS

We found a significant increase in serum concentrations of studied factors in the GO group before immunosuppressive therapy when compared with the control group and decrease after i.v.MP treatment. One month after the end of additional oral MP treatment (Group A2), serum concentrations of HGF and IL-8 still decreased and no significant difference was observed in HGF and IL-8 concentrations when compared with the control group. We did not find the difference in serum concentration of the studied proangiogenic factors between patients in euthyroid and hyperthyroid stage of Graves' disease before MP therapy.

CONCLUSIONS

Serum HGF and IL-8 concentrations are elevated in Graves' disease patients with active Graves' orbitopathy as compared to the healthy control group. Successful management of active Graves' orbitopathy with glucocorticoids is associated with a decrease in HGF and IL-8 serum concentrations.

Predictive Factors of Development of Graves' Ophthalmopathy for Patients with Juvenile Graves' Disease

Background. Due to low incidence of Graves' ophthalmopathy (GO) among children, the manifestation is poorly analyzed, posing a risk to late identification of insidious disease. Purposes. To identify predictive factors that may influence the development of GO in pediatric and young patients with Graves' disease (GD). Methods. A cross-sectional study of patients newly diagnosed with pediatric or juvenile GD during 2002-2012 was conducted at the Hospital of Lithuanian University of Health Sciences. Ocular evaluation was based on European Group on Graves' Orbitopathy survey. The ocular manifestations were analyzed in relation to demographic, environmental, and clinical factors. Results. In total, 130 patients with juvenile GD were included; 29.2% had GO. Median age at GD onset was 17 yrs (IQR 4-29). Main symptoms of GO were eyelids retraction (73.7%), proptosis (65.8%), injection of conjunctiva (42.1%), and eyeball motility disturbance (21.1%). Major significant and independent risk factors for GO development were high initial concentration of FT4 (OR = 5.963), TTHAb (OR = 6.358), stress (OR = 6.030), and smoking (OR = 7.098). Conclusion. The major factors that could influence GO development were smoking, stress, and increased levels of initial TRAb, FT4. Slight proptosis, retraction of eyelids, and conjunctive injection were found as predominant ophthalmological symptoms in juvenile GO.

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.

"Orbiting around" the orbital myositis: clinical features, differential diagnosis and therapy

Orbital myositis (OM) is a rare disease whose clinical heterogeneity and different treatment options represent a diagnostic and therapeutic challenge. We aim to review the state of knowledge on OM, also describing a cohort of patients diagnosed in our centre, to highlight some remarkable clinical features. A literature review was conducted in PubMed and Medline databases. The herein described cohort is composed of seven OM patients, diagnosed according to clinical, laboratory and neuroradiological features, whose clinical data were retrospectively analysed. OM is a non-infectious, inflammatory process primarily involving extraocular eye-muscles. It typically presents as an acute to sub-acute, painful ophthalmoplegia with signs of ocular inflammation, but atypical cases without pain or with a chronic progression have been described. The wide range of OM mimicking diseases make a prompt diagnosis challenging but orbit MRI provides valuable clues for differential diagnosis. Timely treatment is greatly important as OM promptly responds to steroids; nevertheless, partial recovery or relapses often occur. In refractory, recurrent or steroid-intolerant cases other therapeutic options (radiotherapy, immunosuppressants, immunoglobulins) can be adopted, but the most effective therapeutic management is yet to be established. In this review, we provide a detailed clinical description of OM, considering the main differential diagnoses and suggesting the most useful investigations. In light of the currently available data on therapy efficacy, we propose a therapeutic algorithm that may guide neurologists in OM patients' management.

Common Immunosuppressive Monotherapy for Graves' Ophthalmopathy: A Meta-Analysis

Background

Several immunosuppressive therapeutic regimens are widely used to treat Graves’ ophthalmopathy (GO), including oral glucocorticoids (OGC), intravenous glucocorticoids (IVGC), retrobulbar injections of glucocorticoids (ROGC) and orbital radiotherapy (OR). The priority among these is unknown. This meta-analysis investigated the efficacy and tolerability of the above regimens.

Methods

The PubMed, EMBASE, and Cochrane Library databases and the Chinese Biomedicine Database were searched up to November 18, 2014. Randomized controlled trials (RCTs) comparing monotherapies (OGC, IVGC, ROGC and OR) in patients with moderate-to-severe active GO were selected. The main efficacy measures were the response rate, the standard mean difference (SMD) in the reduction in the clinical activity score (CAS) and the mean difference (MD) in proptosis from baseline to the end of treatment. The main tolerability measure was the risk ratio (RR) for adverse events. The pooled estimates and 95% confidence intervals (95% CIs) were calculated using the RevMan software, version 5.1.

Results

Seven published RCTs involving 328 participants were included in the present meta-analysis, including IVGC versus OGC (3 trials), ROGC versus OGC (3 trials) and OR versus OGC (1 trial). IVGC was more effective than OGC in response rate (RR = 1.48, 95% CI = 1.18–1.87) and had an obvious CAS reduction (SMD = 0.69, 95% CI = 0.13–1.25). IVGC caused fewer adverse events than OGC. ROGC and OGC had no statistically significant difference in response rate (RR = 1.16, 95% CI = 0.94–1.42). OR also did not differ significantly compared with OGC (RR = 0.93, 95% CI = 0.54–1.60). ROGC and OR had fewer adverse events, such as weight gain, compared with OGC.

Conclusions

For patients with GO in the moderate-to-severe active phase, current evidence gave priority to IVGC, which had a statistically significant advantage over OGC and caused fewer adverse events. ROGC and OR did not provide greater efficacy than OGC, although better tolerability and fewer adverse events were shown.

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.

A questionnaire survey on the management of Graves' orbitopathy in China: A comparison with Europe and Latin-America

OBJECTIVE

Management of Graves' orbitopathy (GO) continues to be a challenge to clinical endocrinologists. In the last few years, surveys on GO management have succeeded in elucidating trends in Europe and Latin America. To determine how endocrinologists in China assess and treat patients with GO and gain insight into how to make the management of this disease more uniform and standardized.

METHODS

Based on the questionnaire used in the European survey on GO, a questionnaire in China was drafted and circulated to the members of Chinese Society of Endocrinology (CSE) during the annual meeting.

RESULTS

A total of 124 valid responses were analysed. Almost all respondents (94.4%) claimed that a multidisciplinary approach for GO management was valuable. Over 80% of the participants advocated the assessment of exophthalmometry, vision, visual fields by perimetry, eye movements, and fundoscopy. Glucocorticoids were preferred as the first-line therapy by 92.7% of respondents, among them, 59.7% choose the intravenous route. The treatment strategy for GO with intravenous glucocorticoids therapy still remains debatable. Anti-thyroid drugs (ATDs) were the most common choice (72.6%) for first-line therapy of coexisting hyperthyroidism. Treatment options for GO were very similar among Chinese, Latin-American and European respondents, whereas radioactive iodine and surgical treatment were more often indicated for co-existing hyperthyroidism in China.

CONCLUSION

The appropriate treatment for patients with GO is controversial even among thyroid specialists. Further training of thyroid specialists, easier access of patients to multidisciplinary centres and establishment of practice guidelines are required for the management of this condition in China.

An overview of thyroid eye disease

Thyroid eye disease (also known as Graves’ ophthalmopathy) is a complex orbital inflammatory disease, which can be sight threatening, debilitating and disfiguring. This overview discusses the epidemiology, risk factors, pathogenesis, presentation, ophthalmic clinical features, investigations and treatment of thyroid eye disease.

B cell epitope spreading: mechanisms and contribution to autoimmune diseases

While a variety of factors act to trigger or initiate autoimmune diseases, the process of epitope spreading is an important contributor in their development. Epitope spreading is a diversification of the epitopes recognized by the immune system. This process happens to both T and B cells, with this review focusing on B cells. Such spreading can progress among multiple epitopes on a single antigen, or from one antigenic molecule to another. Systemic lupus erythematosus, multiple sclerosis, pemphigus, bullous pemphigoid and other autoimmune diseases, are all influenced by intermolecular and intramolecular B cell epitope spreading. Endocytic processing, antigen presentation, and somatic hypermutation act as molecular mechanisms that assist in driving epitope spreading and broadening the immune response in autoimmune diseases. The purpose of this review is to summarize our current understanding of B cell epitope spreading with regard to autoimmunity, how it contributes during the progression of various autoimmune diseases, and treatment options available.

[Update on endocrine orbitopathy]

Graves' orbitopathy is an autoimmune disease of the ocular adnex connective tissue and most commonly occurs together with Grave's hyperthyroidism. Anti-TSH receptor antibodies are specific for Graves' disease and are related to both the course of thyroid and orbital diseases. An active inflammatory disease stage is followed by an inactive stage of incomplete remission in most patients. Periorbital swelling, proptosis, diplopia and lid retraction severely impair the patients' quality of life. In the active state anti-inflammatory treatment consists of i.v. steroids, off-label use of immunomodulatory medication, selenium and in emergency cases orbital decompression. Fortunately, defects in inactive stable Graves' orbitopathy can be successfully treated by surgery and involve decompression for proptosis reduction, muscle recession to correct diplopia and (finally) lid surgery.

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.

Hyperthyroid monkeys: a nonhuman primate model of experimental Graves' disease

Graves' disease (GD) is a common organ-specific autoimmune disease with the prevalence between 0.5 and 2% in women. Several lines of evidence indicate that the shed A-subunit rather than the full-length thyrotropin receptor (TSHR) is the autoantigen that triggers autoimmunity and leads to hyperthyroidism. We have for the first time induced GD in female rhesus monkeys, which exhibit greater similarity to patients with GD than previous rodent models. After final immunization, the monkeys injected with adenovirus expressing the A-subunit of TSHR (A-sub-Ad) showed some characteristics of GD. When compared with controls, all the test monkeys had significantly higher TSHR antibody levels, half of them had increased total thyroxine (T₄) and free T₄, and 50% developed goiter. To better understand the underlying mechanisms, quantitative studies on subpopulations of CD4+T helper cells were carried out. The data indicated that this GD model involved a mixed Th1 and Th2 response. Declined Treg proportions and increased Th17:Treg ratio are also observed. Our rhesus monkey model successfully mimicked GD in humans in many aspects. It would be a useful tool for furthering our understanding of the pathogenesis of GD and would potentially shorten the distance toward the prevention and treatment of this disease in human.