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Park J, Son Y, Kim J, Kim S, Choi HY. Prognostic factors for thyroid-stimulating immunoglobulin normalization in moderate-to-severe Graves' orbitopathy: a 36-month longitudinal study. BMC Ophthalmol 2024; 24:361. [PMID: 39169342 PMCID: PMC11337896 DOI: 10.1186/s12886-024-03594-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 07/26/2024] [Indexed: 08/23/2024] Open
Abstract
PURPOSE The primary objective of this study was to identify predictive factors linked to the normalization of thyroid-stimulating immunoglobulin (TSI) levels in patients diagnosed with active, moderate-to-severe Graves' orbitopathy (GO). The study also tracked the longitudinal changes in TSI levels over a 36-month period following treatment. METHODS The study population consisted of individuals who were recently diagnosed with active, moderate-to-severe GO and received a 12-week course of intravenous methylprednisolone (IVMP) treatment. A subgroup of patients who did not respond to the initial treatment received an additional 20 Gy of radiation therapy (RTx). TSI levels were monitored at the time of diagnosis, after treatment, and subsequently every 6 months for 36 months. Normalization was defined as a TSI level below 140%. Patients were divdied into two groups with success and failure group depending on whether TSI became normal or not. RESULTS Out of 83 patients, 36 (43.4%) achieved normalized TSI levels within two years post-IVMP treatment. Lower initial TSI levels (< 425%), absence of additional RTx, and early treatment initiation were associated with a higher likelihood of TSI normalization (P = 0.035, P = 0.028, P < 0.001, respectively). Notably, significant differences in TSI level reduction were observed from 18 months post-treatment between the two groups (P = 0.031). A TSI cutoff value of 413% was identified as predictive for normalization at 24 months (P = 0.002). CONCLUSION This study is the first to identify key factors that influence normalization of TSI levels in moderate-to-severe Graves' Orbitopathy. It highlights the importance of early treatment decisions, particularly for patients with initial TSI levels above 425%. Despite the treatment, less than half of the patients achieved TSI normalization within 24 months, underscoring the need for additional research to explore the relationship between TSI levels and the clinical manifestations of chronic GO.
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Affiliation(s)
- Jungyul Park
- Department of Ophthalmology, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 06591, South Korea
| | - Yubin Son
- Department of Ophthalmology, School of Medicine, Pusan National University Hospital, Busan, 49241, Republic of Korea
| | - Jinmi Kim
- Department of Biostatistics, Biomedical Research Institute, Pusan National University Hospital, Busan, 49241, Republic of Korea
| | - Sangsoo Kim
- Department of Endocrinology, School of Medicine, Pusan National University Hospital, Busan, 49241, Republic of Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, 49241, Republic of Korea
| | - Hee-Young Choi
- Department of Ophthalmology, School of Medicine, Pusan National University Hospital, Busan, 49241, Republic of Korea.
- Biomedical Research Institute, Pusan National University Hospital, Busan, 49241, Republic of Korea.
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Beige A, Boustani J, Bouillet B, Truc G. Management of Graves' ophthalmopathy by radiotherapy: A literature review. Cancer Radiother 2024; 28:282-289. [PMID: 38906800 DOI: 10.1016/j.canrad.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 09/01/2023] [Accepted: 09/05/2023] [Indexed: 06/23/2024]
Abstract
Orbital radiotherapy for Graves' ophthalmopathy is an example of non-oncological radiotherapy. First introduced in the 1930s, this treatment has become widely used since the 1980s with several studies showing proof of both effectiveness and safety: a decrease of soft tissue involvement in 70 to 80% of patients and an improvement of ocular mobility in 30 to 80% of patients. Nowadays, it's one of the second line treatment options recognized by the European Group on Graves' orbitopathy in the management of a moderate to severe and active disease after failure of glucocorticoids. In that setting, orbital radiotherapy should be combined with glucocorticoids. To our knowledge, there are no practical recommendations on how orbital radiotherapy should be planned and conducted for Graves' ophthalmopathy. Optimal dose is not defined however the most frequent regimen consists of 20Gy in ten fractions of 2Gy, though other options may yield better results. Lastly, the use of modern technique of radiotherapy such as intensity-modulated radiation therapy may allow a better sparing of organs at risk compared to three-dimensional radiotherapy using lateral opposing fields.
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Affiliation(s)
- A Beige
- Radiation therapy department, centre Georges-François-Leclerc, Dijon, France.
| | - J Boustani
- Radiation therapy department, centre hospitalier universitaire de Besançon, Besançon, France
| | - B Bouillet
- Department of endocrinology and diabetology, centre hospitalier universitaire de Dijon, Dijon, France
| | - G Truc
- Radiation therapy department, centre Georges-François-Leclerc, Dijon, France
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3
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Eckstein A, Welkoborsky HJ. [Interdisciplinary Management of Orbital Diseases]. Laryngorhinootologie 2024; 103:S43-S99. [PMID: 38697143 DOI: 10.1055/a-2216-8879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
Diagnosis and therapy of orbital diseases is an interdisciplinary challenge, in which i.e. otorhinolaryngologists, ophthalmologists, radiologists, radiation therapists, maxillo-facial surgeons, endocrinologists, and pediatricians are involved. This review article describes frequent diseases which both, otolaryngologists and ophthalmologists are concerned with in interdisciplinary settings. In particular the inflammatory diseases of the orbit including orbital complications, autoimmunological diseases of the orbit including Grave´s orbitopathy, and primary and secondary tumors of the orbit are discussed. Beside describing the clinical characteristics and diagnostic steps the article focusses on the interdisciplinary therapy. The review is completed by the presentation of most important surgical approaches to the orbit, their indications and possible complications. The authors tried to highlight the relevant facts despite the shortness of the text.
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Affiliation(s)
| | - H-J Welkoborsky
- Univ. Klinik für Augenheilkunde Universitätsmedizin Essen, Klinik für HNO-Heilkunde, Kopf- und Halschirurgie, Klinikum Nordstadt der KRH
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Men CJ, Amarikwa L, Pham B, Sears C, Clauss K, Lee BW, Lee WW, Pasol J, Ugradar S, Shinder R, Cockerham K, Wester S, Douglas R, Kossler AL. Teprotumumab for the Treatment of Recalcitrant Thyroid Eye Disease. Ophthalmic Plast Reconstr Surg 2024; 40:276-285. [PMID: 37972960 PMCID: PMC11090759 DOI: 10.1097/iop.0000000000002564] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
PURPOSE Teprotumumab, an insulin-like growth factor 1 receptor monoclonal antibody, is FDA-approved to treat thyroid eye disease (TED). The initial clinical trials excluded patients with previous orbital irradiation, surgery, glucocorticoid use (cumulative dose >1 gm), or prior biologic treatment. Information on the use of teprotumumab for patients who failed prior therapy is limited. Our purpose is to characterize the efficacy of teprotumumab for the treatment of recalcitrant TED. METHODS This is a multicenter retrospective study of all patients treated with teprotumumab for moderate-to-severe TED after failing conventional therapy with corticosteroids, orbital radiation, surgical decompression, biologics, or other steroid-sparing medications. Treatment failure was defined as an incomplete response to or reactivation after previous treatment. Only patients who received at least 4 infusions of teprotumumab were included in the analysis. Primary outcome measures comprised proptosis response (≥2 mm reduction in the study eye without a similar increase in the other eye), clinical activity score (CAS) response (≥2-point reduction in CAS), and diplopia response (≥1 point improvement in Gorman diplopia score in patients with baseline diplopia) following treatment. Adverse events and risk factors for recalcitrant disease were also evaluated. RESULTS Sixty-six patients were included in this study, 46 females and 20 males. Average age was 59.3 years (range 29-93). The mean duration of disease from TED diagnosis to first infusion was 57.8 months. The proptosis, CAS, and diplopia responses in this recalcitrant patient population were 85.9%, 93.8%, and 69.1%, respectively. Patients experienced a mean reduction in proptosis of 3.1 ± 2.4 mm and a mean improvement in CAS of 3.8 ± 1.6. Patients who underwent prior decompression surgery experienced a statistically significant decrease in diplopia response (46.7% vs. 77.5%, p = 0.014) and proptosis response (75.0% vs. 90.9%, p = 0.045) when compared with nondecompression patients. Additionally, there were no significant differences in proptosis, CAS, and diplopia responses between patients with acute (defined as disease duration <1 year) versus chronic (disease duration ≥1 year) TED. While most adverse events were mild to moderate, 4 patients reported serious adverse events related to persistent hearing loss. CONCLUSIONS Patients with recalcitrant TED demonstrated a significant improvement after teprotumumab in each of the primary study outcomes. The degree of proptosis reduction, diplopia response, and CAS improvement in the recalcitrant group were similar to those of treatment-naïve patients from the pivotal clinical trials. Patients with a prior history of orbital decompression, however, demonstrated poor improvement in diplopia and less reduction in proptosis than surgery naïve patients. These results indicate that teprotumumab is a treatment option for the treatment of patients with TED recalcitrant to prior medical therapies.
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Affiliation(s)
- Clara J Men
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Linus Amarikwa
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Brandon Pham
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida, U.S.A
| | - Connie Sears
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Kevin Clauss
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida, U.S.A
| | - Bradford W Lee
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida, U.S.A
- Department of Surgery, Ophthalmology Division, University of Hawai'i John A. Burns School of Medicine, Honolulu, Hawaii, U.S.A
| | - Wendy W Lee
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida, U.S.A
| | - Joshua Pasol
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida, U.S.A
| | - Shoaib Ugradar
- Private Practice, Beverly Hills, Los Angeles, California, U.S.A
| | - Roman Shinder
- Department of Ophthalmology, SUNY Downstate Medical, Brooklyn, New York, U.S.A
| | - Kimberly Cockerham
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, U.S.A
- Private Practice, San Diego, California, U.S.A
| | - Sara Wester
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida, U.S.A
| | - Raymond Douglas
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A
| | - Andrea L Kossler
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, U.S.A
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North VS, Dolman PJ, Garrity JA, Kazim M. Disease Modulation Versus Modification: A Call for Revised Outcome Metrics in the Treatment of Thyroid Eye Disease. Ophthalmic Plast Reconstr Surg 2024; 40:156-160. [PMID: 38285956 DOI: 10.1097/iop.0000000000002591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
PURPOSE This perspective introduces the concepts of disease-modulating and -modifying therapy for thyroid eye disease and offers novel metrics for therapeutic outcomes. METHODS A focused literature review was performed. RESULTS Modulators are treatments that suppress disease symptoms whereas modifiers alter the natural history of a disease. Though many drugs are capable of exhibiting both effects, consideration of a drug's primary effect is useful when considering therapeutic options. For thyroid eye disease, corticosteroids and teprotumumab are effective at modulating many signs and symptoms of the disease, particularly those related to soft tissue inflammation. Orbital radiotherapy and rituximab have demonstrated effectiveness at durably modifying the natural history of thyroid eye disease. CONCLUSIONS Outcome metrics should reflect the unique therapeutic objectives associated with disease modulation and modification. This conceptual framework should guide treatment of thyroid eye disease.
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Affiliation(s)
- Victoria S North
- Department of Ophthalmology, Orbit and Oculoplastic Surgery, Tufts Medical Center, Tufts University, Boston, Massachusetts, U.S.A
| | - Peter J Dolman
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - James A Garrity
- Department of Ophthalmology, Oculoplastic Surgery, Lake Region Medical Group, Fergus Falls, Minnesota, U.S.A
| | - Michael Kazim
- Department of Ophthalmology, Oculoplastic and Orbital Surgery, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York City, New York, U.S.A
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Eckstein A, Stöhr M, Görtz GE, Gulbins A, Möller L, Fuehrer-Sakel D, Oeverhaus M. Current Therapeutic Approaches for Graves' Orbitopathy - are Targeted Therapies the Future? Klin Monbl Augenheilkd 2024; 241:48-68. [PMID: 37799096 DOI: 10.1055/a-2186-5548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Graves' orbitopathy is an autoimmune disease of the orbit that most frequently occurs with Graves' hyperthyroidism. The occurrence of autoantibodies directed against the TSH receptor (TRAb) is of central importance for the diagnosis and pathogenesis. These autoantibodies are mostly stimulating, and induce uncontrolled hyperthyroidism and tissue remodelling in the orbit and more or less pronounced inflammation. Consequently, patients suffer to a variable extent from periocular swelling, exophthalmos, and fibrosis of the eye muscles and thus restrictive motility impairment with double vision. In recent decades, therapeutic approaches have mainly comprised immunosuppressive treatments and antithyroid drug therapy for hyperthyroidism to inhibit thyroid hormone production. With the recognition that TRAb also activates an important growth factor receptor, IGF1R (insulin-like growth factor 1 receptor), biological agents have been developed. Teprotumumab (an inhibitory IGF1R antibody) has already been approved in the USA and the therapeutic effects are enormous, especially with regard to the reduction of exophthalmos. Side effects are to be considered, especially hyperglycaemia and hearing loss. It is not yet clear whether the autoimmune reaction (development of the TRAb/attraction of immunocompetent cells) is also influenced by anti-IGF1R inhibiting agents. Recurrences after therapy show that the inhibition of antibody development must be included in the therapeutic concept, especially in severe cases.
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Affiliation(s)
- Anja Eckstein
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Deutschland
| | - Mareile Stöhr
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Deutschland
| | - Gina-Eva Görtz
- Labor für Molekulare Augenheilkunde, Universität Duisburg-Essen, Duisburg, Deutschland
| | - Anne Gulbins
- Labor für Molekulare Augenheilkunde, Universität Duisburg-Essen, Duisburg, Deutschland
| | - Lars Möller
- Klinik für Endokrinologie, Diabetologie und Stoffwechsel, Universitätsklinikum Essen, Deutschland
| | - Dagmar Fuehrer-Sakel
- Klinik für Endokrinologie, Diabetologie und Stoffwechsel, Universitätsklinikum Essen, Deutschland
| | - Michael Oeverhaus
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Deutschland
- Gemeinschaftspraxis Dres. Oeverhaus & Weiß, Rietberg, Deutschland
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7
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Potvin ARGG, Pakdel F, Saeed P. Dysthyroid Optic Neuropathy. Ophthalmic Plast Reconstr Surg 2023; 39:S65-S80. [PMID: 38054987 DOI: 10.1097/iop.0000000000002555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
PURPOSE Dysthyroid optic neuropathy (DON) is a sight-threatening complication of thyroid eye disease (TED). This review provides an overview of the epidemiology, pathogenesis, diagnosis, and current therapeutic options for DON. METHODS A literature review. RESULTS DON occurs in about 5% to 8% of TED patients. Compression of the optic nerve at the apex is the most widely accepted pathogenic mechanism. Excessive stretching of the nerve might play a role in a minority of cases. Increasing age, male gender, smoking, and diabetes mellitus have been identified as risk factors. Diagnosis of DON is based on a combination of ≥2 clinical findings, including decreased visual acuity, decreased color vision, relative afferent pupillary defect, visual field defects, or optic disc edema. Orbital imaging supports the diagnosis by confirming apical crowding or optic nerve stretching. DON should be promptly treated with high-dose intravenous glucocorticoids. Decompression surgery should be performed, but the response is incomplete. Radiotherapy might play a role in the prevention of DON development and may delay or avoid the need for surgery. The advent of new biologic-targeted agents provides an exciting new array of therapeutic options, though more research is needed to clarify the role of these medications in the management of DON. CONCLUSIONS Even with appropriate management, DON can result in irreversible loss of visual function. Prompt diagnosis and management are pivotal and require a multidisciplinary approach. Methylprednisolone infusions still represent first-line therapy, and surgical decompression is performed in cases of treatment failure. Biologics may play a role in the future.
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Affiliation(s)
- Arnaud R G G Potvin
- Orbital Center Amsterdam, Department of Ophthalmology, Amsterdam University Medical Center, location AMC, The Netherlands
| | - Farzad Pakdel
- Department of Oculo-Facial Plastic Surgery, Tehran University of Medical Sciences, Farabi Hospital, Tehran, Iran
| | - Peerooz Saeed
- Orbital Center Amsterdam, Department of Ophthalmology, Amsterdam University Medical Center, location AMC, The Netherlands
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8
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Jang JH, Park JW, Park KA, Kim YD, Woo KI. Early response to intravenous methylprednisolone therapy for restrictive myopathy in patients with thyroid eye disease. Graefes Arch Clin Exp Ophthalmol 2023; 261:2375-2382. [PMID: 36808229 DOI: 10.1007/s00417-023-06013-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 02/23/2023] Open
Abstract
PURPOSE To report the therapeutic efficacy of intravenous methylprednisolone (IVMP) in patients with restrictive myopathy caused by thyroid eye disease (TED). METHODS The present prospective uncontrolled study comprised 28 patients with TED and restrictive myopathy who presented with diplopia that had developed within 6 months before their visit. All patients were treated with IVMP for 12 weeks. Deviation angle, limitation of extraocular muscle (EOM) movement, binocular single vision score, Hess score, clinical activity score (CAS), modified NOSPECS score, exophthalmometric value, and the size of EOMs on computed tomography were evaluated. The patients were divided into two groups: those whose deviation angle had decreased or remained unchanged 6 months after treatment (group 1; n = 17) and those whose deviation angle had increased in that time (group 2; n = 11). RESULTS The mean CAS of the whole cohort significantly decreased from baseline to 1 month and 3 months after treatment (P = 0.03 and P = 0.02, respectively). The mean deviation angle significantly increased from baseline to 1, 3, and 6 months (P = 0.01, P < 0.01, and P < 0.01, respectively). The deviation angle decreased in 10 (36%), remained constant in seven (25%), and increased in 11 (39%) of the 28 patients. When groups 1 and 2 were compared, no single variable was identified as a cause of deviation angle deterioration (P > 0.05). CONCLUSIONS When treating patients with TED who have restrictive myopathy, physicians should be aware that some patients show worsening of the strabismus angle despite inflammation control with IVMP therapy. Uncontrolled fibrosis can result in motility deterioration.
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Affiliation(s)
- Jae Ho Jang
- Department of Ophthalmology, Dongguk University Gyeongju Hospital, Gyeongju, Gyeongsangbuk-Do, Republic of Korea
| | - Ji Woong Park
- Seoul Eye Clinic, Anyang, Gyeonggi-Do, Republic of Korea
| | - Kyung-Ah Park
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Republic of Korea
| | | | - Kyung In Woo
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, Republic of Korea.
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Takahashi Y, Vaidya A. Diagnosis and Management of Dysthyroid Optic Neuropathy. Int Ophthalmol Clin 2023; 63:233-248. [PMID: 37439621 DOI: 10.1097/iio.0000000000000452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
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10
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Currò N, Guastella C, Pirola G, Calonghi B, Bottari de Castello A, Fazio M, di Benedetto S, Minorini V, Daga M, Contarino A, Muller I, Arosio M, Viola F, Pignataro L, Salvi M. CLINICAL AND VISUAL OUTCOMES OF DYSTHYROID OPTIC NEUROPATHY AFTER SURGICAL ORBITAL DECOMPRESSION. Thyroid 2023. [PMID: 37140534 DOI: 10.1089/thy.2022.0564] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND Current guidelines suggest high dose steroids as first line treatment for dysthyroid optic neuropathy (DON). When steroids fail, decompressive surgery is mandatory. METHODS We conducted a single-centre, retrospective cohort study in a tertiary care combined Thyroid-Eye clinic in Milan, Italy. We studied 88 orbits of 56 patients which were submitted to surgical orbital decompression to treat DON from 2005 to 2020. Of these, 33 orbits (37.5%) underwent surgery as first line treatment for DON while the other 55 (62.5%) were decompressed after being unresponsive to very high dose steroids. Previous orbital surgery, concurrent neurological or ophthalmologic diseases or incomplete follow-up were considered as exclusion criteria from this study. Surgery was considered successful if no further decompression was needed to preserve vision. Pinhole best corrected visual acuity (p-BCVA), color sensitivity, automated visual field, pupil reflexes, optic disc and fundus appearance, exophtalmometry and ocular motility were studied before and after surgery (1 week, 1, 3, 6 and 12 months). Activity of Graves' Orbitopathy (GO) was graded using a clinical activity score (CAS). RESULTS Surgery was successful in 77 orbits (87.5%). The remaining 11 orbits (13%) needed further surgery to treat DON definitively. All parameters of visual function improved significantly at follow up and GO inactivated (CAS<3) within one month. At three months, all 77 responding orbits had p-BCVA > 0.63 while all of the 11 non-responding orbits had p-BCVA ≤ 0.63. Visual field parameters and color sensitivity were not associated with response to surgery. High dose steroid treatment before surgery was associated to a better response rate (96% vs. 73%; P=0.004). Balanced decompression was associated with a higher response rate compared to medial wall decompression (96% vs. 80%; P=0.04). A significant inverse correlation was observed between final p-BCVA and patient's age (r = -0.42; P=0.0003). CONCLUSIONS Surgical decompression was found to be a very effective treatment for DON. In this study, all clinical parameters improved after surgery and further intervention was rarely needed.
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Affiliation(s)
- Nicola Currò
- Policlinico di Milano, 9339, Ophthalmology Unit, Departement of Surgery, Milan, Lombardia, Italy;
| | | | - Giacinta Pirola
- Policlinico di Milano, 9339, Ophthalmology Unit, department of Surgery, Milan, Lombardia, Italy;
| | - Barbara Calonghi
- Policlinico di Milano, 9339, Ophthalmology Unit, Department of Surgery, Milan, Lombardia, Italy;
| | | | - Mariachiara Fazio
- Policlinico di Milano, 9339, Ophthalmology Unit, Department of Surgery, Milan, Lombardia, Italy;
| | - Sabina di Benedetto
- Policlinico di Milano, 9339, Ophthalmology Unit, Department of Surgery, Milan, Lombardia, Italy;
| | - Valeria Minorini
- Policlinico di Milano, 9339, Ophthalmology Unit, Department of Surgery, Milan, Lombardia, Italy;
| | - Marco Daga
- Policlinico of Milan, 9339, Otolaringology Unit, Department of Surgery, Milan, Lombardia, Italy;
| | - Andrea Contarino
- Policlinico di Milano, 9339, Endocrinology Unit, department of Clinical Sciences and Community Health, Milan, Lombardia, Italy;
| | - Ilaria Muller
- Policlinico di Milano, 9339, Endocrinology Unit, department of Clinical Sciences and Community Health, Milan, Lombardia, Italy;
| | - Maura Arosio
- Policlinico di Milano, 9339, Endocrinology Unit, department of Clinical Sciences and Community Health, Milan, Lombardia, Italy;
| | - Francesco Viola
- Policlinico di Milano, 9339, Ophthalmology Unit, Department of Surgery, Milan, Lombardia, Italy;
| | - Lorenzo Pignataro
- Policlinico di Milano, 9339, Otolaringology Unit, Department of Surgery, Milan, Lombardia, Italy;
| | - Mario Salvi
- Policlinico di Milano, 9339, Endocrinology Unit, department of Clinical Sciences and Community Health, Milan, Lombardia, Italy;
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11
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Pelewicz-Sowa M, Miśkiewicz P. Dysthyroid optic neuropathy: emerging treatment strategies. J Endocrinol Invest 2023:10.1007/s40618-023-02036-0. [PMID: 36802028 DOI: 10.1007/s40618-023-02036-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 02/06/2023] [Indexed: 02/21/2023]
Abstract
PURPOSE Dysthyroid optic neuropathy (DON) is a rare sight-threatening complication of Graves' disease. First-line treatment for DON consists of high-dose intravenous methylprednisolone (ivMP), followed by immediate orbital decompression (OD) if the response is poor or absent as recommended by the 2021 European Group on Graves' orbitopathy guidelines. The safety and efficacy of the proposed therapy have been proven. However, consensus regarding possible therapeutic options for patients with contraindications to ivMP/OD or resistant form of disease is missing. This paper aims to provide and summarize all available data regarding possible alternative treatment strategies for DON. METHODS A comprehensive literature search within an electronic database was performed including data published until December 2022. RESULTS Overall, 52 articles describing use of emerging therapeutic strategies for DON were identified. Collected evidence indicates that biologics, including teprotumumab and tocilizumab, may be considered as an important possible treatment option for DON patients. Rituximab should be avoided in DON due to conflicting data and risk of adverse events. Orbital radiotherapy could be beneficial for patients with restricted ocular motility classified as poor surgical candidates. CONCLUSION Only a limited number of studies have been dedicated to the therapy of DON, mostly retrospective with a small sample size. Clear criteria regarding diagnosis and resolution of DON do not exist, which restricts comparison of therapeutic outcomes. Randomized clinical trials and comparison studies with long-term follow-ups are necessary to verify the safety and efficacy of each therapeutic option for DON.
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Affiliation(s)
- M Pelewicz-Sowa
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, 02-091, Warsaw, Poland
| | - P Miśkiewicz
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, 02-091, Warsaw, Poland.
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12
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Thyroid Eye Disease. LIFE (BASEL, SWITZERLAND) 2022; 12:life12122084. [PMID: 36556449 PMCID: PMC9787503 DOI: 10.3390/life12122084] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/01/2022] [Accepted: 12/08/2022] [Indexed: 12/15/2022]
Abstract
Thyroid eye disease (TED), an autoimmune inflammatory disorder of the orbit, presents with a potential array of clinical sequelae. The pathophysiology behind TED has been partially characterized in the literature. There remain certain elusive mechanisms welcoming of research advances. Disease presentation can vary, but those that follow a characteristic course start mild and increase in severity before plateauing into an inactive phase. Diagnosis and evaluation include careful physical examination, targeted laboratory work up, appropriate imaging studies, and tailored treatment regimens. Special consideration may apply to certain populations, such as pediatric and pregnant patients.
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Burch HB, Perros P, Bednarczuk T, Cooper DS, Dolman PJ, Leung AM, Mombaerts I, Salvi M, Stan MN. Management of Thyroid Eye Disease: A Consensus Statement by the American Thyroid Association and the European Thyroid Association. Thyroid 2022; 32:1439-1470. [PMID: 36480280 PMCID: PMC9807259 DOI: 10.1089/thy.2022.0251] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Thyroid eye disease (TED) remains challenging for clinicians to evaluate and manage. Novel therapies have recently emerged, and their specific roles are still being determined. Most patients with TED develop eye manifestations while being treated for hyperthyroidism and under the care of endocrinologists. Endocrinologists, therefore, have a key role in diagnosis, initial management, and selection of patients who require referral to specialist care. Given that the need for guidance to endocrinologists charged with meeting the needs of patients with TED transcends national borders, and to maximize an international exchange of knowledge and practices, the American Thyroid Association and European Thyroid Association joined forces to produce this consensus statement.
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Affiliation(s)
- Henry B. Burch
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Endocrinology Division, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Address correspondence to: Henry B. Burch, MD, National Institute of Diabetes and Digestive and Kidney Diseases, Division of Diabetes, Endocrinology, & Metabolic Diseases, National Institutes of Health, 6707 Democracy Blvd, Room 5053, Bethesda, MD 20892-0001, USA
| | - Petros Perros
- Department of Endocrinology, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - David S. Cooper
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Peter J. Dolman
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, Canada
| | - Angela M. Leung
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, UCLA David Geffen School of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Ilse Mombaerts
- Department of Ophthalmology, University Hospitals Leuven, Leuven, Belgium
| | - Mario Salvi
- Department of Clinical and Community Services, Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Marius N. Stan
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota, USA
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Burch HB, Perros P, Bednarczuk T, Cooper DS, Dolman PJ, Leung AM, Mombaerts I, Salvi M, Stan MN. Management of thyroid eye disease: a Consensus Statement by the American Thyroid Association and the European Thyroid Association. Eur Thyroid J 2022; 11:e220189. [PMID: 36479875 PMCID: PMC9727317 DOI: 10.1530/etj-22-0189] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 11/30/2022] Open
Abstract
Thyroid eye disease (TED) remains challenging for clinicians to evaluate and manage. Novel therapies have recently emerged, and their specific roles are still being determined. Most patients with TED develop eye manifestations while being treated for hyperthyroidism and under the care of endocrinologists. Endocrinologists, therefore, have a key role in diagnosis, initial management, and selection of patients who require referral to specialist care. Given that the need for guidance to endocrinologists charged with meeting the needs of patients with TED transcends national borders, and to maximize an international exchange of knowledge and practices, the American Thyroid Association and European Thyroid Association joined forces to produce this Consensus Statement.
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Affiliation(s)
- Henry B Burch
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Endocrinology Division, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Petros Perros
- Department of Endocrinology, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Peter J Dolman
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, Canada
| | - Angela M Leung
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, UCLA David Geffen School of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Ilse Mombaerts
- Department of Ophthalmology, University Hospitals Leuven, Leuven, Belgium
| | - Mario Salvi
- Department of Clinical and Community Services, Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Marius N Stan
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
BACKGROUND AND AIMS This review aims to summarize current and emerging therapies for treatment of thyroid eye disease (TED), in the light of novel understanding of pathogenetic mechanisms, leading to new treatment options and clinical trials. METHODS We reviewed and analyzed peer-reviewed literature reporting recent translational studies and clinical trials in the treatment of TED. Searches were made at www.pubmed.gov with keywords "thyroid eye disease," "Graves' ophthalmopathy," "thyroid orbitopathy," and "Graves' orbitopathy." RESULTS Surgery is reserved for rehabilitation in chronic TED or for emergent compressive optic neuropathy. Oral and intravenous glucocorticoid therapy has been used for decades with variable efficacy in acute TED, but results may be temporary and side effects significant. Nonsteroidal oral immunosuppressive agents offer modest benefit in TED. Several immunomodulatory monoclonal antibodies, including rituximab and tocilizumab, have shown efficacy for inactivating TED. Recently, teprotumumab, an insulin-like growth factor 1 receptor (IGF-1R) inhibitor, has demonstrated significant improvement in proptosis, clinical activity score, diplopia, and quality of life in patients with active TED, with good tolerability. Newly proposed TED therapies, currently in preclinical and clinical trial phases, include thyroid-stimulating hormone (TSH) receptor inhibitory drugs, RVT-1401, local anti-vascular endothelial growth factor therapy, IGF-1R drugs delivered subcutaneously and orally, and desensitization to the TSH receptor with modified TSH receptor peptides. CONCLUSION New, albeit incomplete, understanding of the molecular mechanisms of TED has led to new promising therapies and offered improved outcomes in TED patients. Their full role and their relationship to classical immune suppression should be clarified over the next few years.
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Affiliation(s)
- Giuseppe Barbesino
- Correspondence: Giuseppe Barbesino, MD, Thyroid Unit, Massachusetts General Hospital, Harvard Medical School, WACC730S, 15 Parkman St, Boston, MA 02114, USA.
| | - Mario Salvi
- Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Suzanne K Freitag
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
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Yu CY, Ford RL, Wester ST, Shriver EM. Update on thyroid eye disease: Regional variations in prevalence, diagnosis, and management. Indian J Ophthalmol 2022; 70:2335-2345. [PMID: 35791115 PMCID: PMC9426067 DOI: 10.4103/ijo.ijo_3217_21] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Thyroid eye disease (TED) is a rare disease that can lead to decreased quality of life, permanent disfigurement, and vision loss. Clinically, TED presents with exophthalmos, periorbital edema, extraocular muscle dysfunction, and eyelid retraction, and can lead to vision-threatening complications such as exposure to keratopathy and dysthyroid optic neuropathy (DON). Over the last several years, significant advancements have been made in the understanding of its pathophysiology as well as optimal management. Ethnic variations in the prevalence, clinical presentation, and risk of vision-threatening complications of TED are summarized, and risk factors associated with TED are discussed. Additionally, significant advances have been made in the management of TED. The management of TED traditionally included anti-inflammatory medications, orbital radiation therapy, orbital surgical decompression, and biologic therapies. Most recently, targeted therapies such as teprotumumab, an insulin-like growth factor-1 receptor antagonist, have been studied in the context of TED, with promising initial data. In this review, updates in the understanding and management of TED are presented with a focus on the international variations in presentation and management.
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Affiliation(s)
- Caroline Y Yu
- Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, IA, USA
| | - Rebecca L Ford
- Department of Ophthalmology, Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Sara T Wester
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Erin M Shriver
- Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, IA, USA
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Lu TJ, Amarikwa L, Sears CM, Kossler AL. Advances in the Treatment of Thyroid Eye Disease Associated Extraocular Muscle Myopathy and Optic Neuropathy. Curr Neurol Neurosci Rep 2022; 22:313-325. [PMID: 35614367 PMCID: PMC10812872 DOI: 10.1007/s11910-022-01194-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To review emerging treatments for thyroid eye disease (TED) associated extraocular muscle myopathy and dysthyroid optic neuropathy (DON). RECENT FINDINGS Emerging targeted biologic therapies may alter the disease course in TED. Teprotumumab, a type I insulin-like growth factor receptor inhibitor, is the most recent addition to the treatments available for TED-associated extraocular muscle myopathy causing diplopia. Small studies also suggest a potential therapeutic benefit for DON. Various recent studies have also expanded our knowledge on conventional TED therapies. The therapeutic landscape of TED and its sequelae has evolved in recent years. New targeted therapies have the potential to reduce the extraocular muscle and orbital volume expansion which can lead to diplopia and vision loss from optic nerve compression. Longer term efficacy and durability data is needed to determine the role biologics, such as teprotumumab, should play in the treatment of TED patients compared to the current standard of care.
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Affiliation(s)
- Tracy J Lu
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA, 94303, USA
| | - Linus Amarikwa
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA, 94303, USA
| | - Connie M Sears
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA, 94303, USA
| | - Andrea L Kossler
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA, 94303, USA.
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Sobel RK, Aakalu VK, Vagefi MR, Foster JA, Tao JP, Freitag SK, Wladis EJ, McCulley TJ, Yen MT. Orbital Radiation for Thyroid Eye Disease: A Report by the American Academy of Ophthalmology. Ophthalmology 2021; 129:450-455. [PMID: 34895729 DOI: 10.1016/j.ophtha.2021.10.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 10/27/2021] [Accepted: 10/29/2021] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To review the current literature on the safety and efficacy of orbital radiation for the management of thyroid eye disease (TED). METHODS A literature search was conducted last in February 2021 of the PubMed database to identify all articles published in the English language on original research that assessed the effect of orbital radiation on TED. The search identified 55 articles, and 18 met the inclusion criteria for this assessment. A panel methodologist then assigned a level of evidence rating for each study, and all of them were rated level III. RESULTS Two large retrospective studies demonstrated the efficacy of radiation treatment, with or without corticosteroid use, in preventing or treating compressive optic neuropathy (CON). Three studies highlighted the role of orbital radiation therapy (RT) to facilitate the tapering of corticosteroids. Several other studies showed a possible role for RT to improve diplopia and soft tissue signs. CONCLUSIONS Although no level I or level II evidence exists, the best available evidence suggests that orbital radiation, used with or without corticosteroids, is efficacious in preventing CON, improving motility restriction, and decreasing clinical activity in TED. Orbital radiation also may facilitate a corticosteroid taper. Together, these studies show that RT seems to modify the active phase of TED. Short-term risks of orbital radiation are minor, but long-term outcome data are lacking.
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Affiliation(s)
- Rachel K Sobel
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vinay K Aakalu
- Illinois Eye and Ear Infirmary, University of Illinois College of Medicine at Chicago, Chicago, Illinois
| | - M Reza Vagefi
- Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | - Jill A Foster
- Ophthalmic Surgeons and Consultants of Ohio, Columbus, Ohio
| | - Jeremiah P Tao
- Gavin Herbert Eye Institute, University of California, Irvine School of Medicine, Irvine, California
| | - Suzanne K Freitag
- Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Edward J Wladis
- Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical Center, Albany (Slingerlands), New York
| | - Timothy J McCulley
- Ruiz Department of Ophthalmology and Visual Sciences, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas
| | - Michael T Yen
- Cullen Eye Institute, Baylor College of Medicine, Houston, Texas
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Xu MN, Pan ZQ, Tu YH, Tao HQ, Shi KS, Wu WC. Therapeutic difference between orbital decompression and glucocorticoids administration as the first-line treatment for dysthyroid optic neuropathy: a systematic review. Int J Ophthalmol 2021; 14:1107-1113. [PMID: 34282398 DOI: 10.18240/ijo.2021.07.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 03/05/2021] [Indexed: 11/23/2022] Open
Abstract
To assess all available data to compare the efficacy of glucocorticoids treatment and orbital decompression for dysthyroid optic neuropathy (DON). PubMed, EMBASE, the Cochrane Library databases as well as other sources were searched by two independent reviewers followed by extensive hand-searching for the identification of relevant studies. The primary outcomes were the improvement in visual acuity and responder rate. Secondary outcomes were the proptosis reduction, change in diplopia, and clinical activity score (CAS). One randomized controlled trial, three retrospective case series and one prospective case series met the inclusion criteria. They were divided into intravenous high-dose glucocorticoids (ivGC) group and orbital decompression (OD) group. Both groups demonstrated improvement in visual acuity. In addition, the proportion of patients with improved vision in OD group was higher than that in ivGC group (P<0.001). Post-treatment proptosis reduction was also reported in both groups. Overall, weighted mean in proptosis reduction estimated at 1.64 and 5.45 mm in patients treated with ivGC and OD respectively. This study also presented results regarding pre-existing and new-onset diplopia. Apart from diplopia, a wide variety of minor and major complications were noted in 5 included studies. The most common complication in ivGC group and OD group was Cushing's syndrome and epistaxis respectively. The present systematic review shows that both glucocorticoids treatment and OD are effective in treating DON and OD may work better in improving visual acuity and reducing proptosis. However, high-quality, large-sample, controlled studies need to be performed in the future.
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Affiliation(s)
- Ming-Na Xu
- The Eye Hospital of Wenzhou Medical University, Wenzhou 325027, Zhejiang Province, China
| | - Zhao-Qi Pan
- The Eye Hospital of Wenzhou Medical University, Wenzhou 325027, Zhejiang Province, China
| | - Yun-Hai Tu
- The Eye Hospital of Wenzhou Medical University, Wenzhou 325027, Zhejiang Province, China
| | - He-Qing Tao
- Peking University Third Hospital, Beijing 100000, China
| | - Ke-Si Shi
- The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Wen-Can Wu
- The Eye Hospital of Wenzhou Medical University, Wenzhou 325027, Zhejiang Province, China
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Sears CM, Wang Y, Bailey LA, Turbin R, Subramanian PS, Douglas R, Cockerham K, Kossler AL. Early efficacy of teprotumumab for the treatment of dysthyroid optic neuropathy: A multicenter study. Am J Ophthalmol Case Rep 2021; 23:101111. [PMID: 34113737 PMCID: PMC8170359 DOI: 10.1016/j.ajoc.2021.101111] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 03/14/2021] [Accepted: 04/19/2021] [Indexed: 11/20/2022] Open
Abstract
Purpose To study post-interventional findings in patients with dysthyroid optic neuropathy (DON) treated with teprotumumab. Observations In this multicenter observational Case series, patients with DON were treated with teprotumumab, an insulin-like growth factor I receptor inhibitor (10 mg/kg for the first infusion then 20 mg/kg for subsequent infusions, every three weeks for a total 8 infusions). This study included patients with acute and chronic thyroid eye disease (TED) with DON who had failed conventional therapies and were not candidates for surgical decompression. Data collected included best corrected visual acuity (BCVA), color vision, RAPD when present, and orbital CT or MRI. Proptosis, clinical activity score (CAS), Gorman diplopia score (GDS), and Humphrey visual fields (HVF) were also evaluated. Ten patients (6 women, 4 men) with an average age 64 years old were included in this study. Mean follow up after completion of infusions was 15 weeks. Baseline visual acuity (VA) impairment ranged from hand motion (HM) to 20/25 in affected eyes. All patients had pre-treatment orbital CT or MRI that confirmed orbital apex compression. Seventy percent of patients had objective improvement in DON after 2 infusions of teprotumumab measured as significant improvement in visual acuity, resolution of RAPD, or both. After completion of treatment, affected eyes had a mean BCVA improvement of 0.87 logMAR (p=0.0207), proptosis reduction of 4.7 mm (p<0.00001), CAS improvement of 5.25 points (p<0.00001), and GDS improvement of 0.75 points (p=0.160). All 6 patients who presented with an RAPD had resolution or improvement of RAPD. All 7 patients who presented with color vision deficits had normalization or improvement of color vision. Conclusions and Importance Teprotumumab infusions resulted in medical decompression and objective resolution or improvement of dysthyroid optic neuropathy. Most patients had rapid improvement of visual acuity and reversal of RAPD. Post-infusion imaging demonstrated reduction in extraocular muscle size that correlated with improvement in visual dysfunction. However, patients who presented with longstanding severe visual loss had limited improvement. There was no recurrence of DON after completion of teprotumumab in our cohort. Teprotumumab is effective for the treatment of dysthyroid optic neuropathy. Most patients demonstrated rapid objective improvement after 2 infusions. Visual acuity improved and relative afferent pupillary defect resolved after treatment. Orbital imaging showed improvement of orbital apex crowding after treatment. Patients with longstanding severe vision loss had limited improvement in visual acuity.
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Affiliation(s)
- Connie M Sears
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Yao Wang
- Private Practice, Beverly Hills, CA, USA
| | | | - Roger Turbin
- Institute of Ophthalmology and Visual Science, Department of Ophthalmology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Prem S Subramanian
- Department of Ophthalmology, University of Colorado School of Medicine and Sue Anschutz-Rodgers UC Health Eye Center, Aurora, CO, USA
| | | | - Kimberly Cockerham
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA.,Central Valley Eye Medical Group; Stockton, CA, USA
| | - Andrea L Kossler
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
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Mehmet A, Panagiotopoulou EK, Konstantinidis A, Papagoras C, Skendros P, Dardabounis D, Mikropoulou AM, Labiris G. Α Case of Severe Thyroid Eye Disease Treated with Tocilizumab. ACTA MEDICA (HRADEC KRÁLOVÉ) 2021; 64:64-69. [PMID: 33855963 DOI: 10.14712/18059694.2021.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This is a case report describing a patient with severe thyroid eye disease complicated with dysthyroid optic neuropathy that was unresponsive to intravenous steroids and orbital radiotherapy but responded well to intravenous tocilizumab.
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Affiliation(s)
- Aysel Mehmet
- University Eye Clinic, University Hospital of Alexandroupolis, Greece.
| | | | | | - Charalampos Papagoras
- University Department of Internal Medicine, University Hospital of Alexandroupolis, Greece
| | - Panagiotis Skendros
- University Department of Internal Medicine, University Hospital of Alexandroupolis, Greece
| | | | | | - Georgios Labiris
- University Eye Clinic, University Hospital of Alexandroupolis, Greece
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Allen RC, Bradley EA, Fante RG, Lucarelli MJ. A Perspective on the Current Role of Teprotumumab in Treatment of Thyroid Eye Disease. Ophthalmology 2021; 128:1125-1128. [PMID: 33823982 DOI: 10.1016/j.ophtha.2021.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 12/27/2022] Open
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Siktberg J, Sobel RK. Current Role and Historical Roots of Radiotherapy in Thyroid Eye Disease. Int Ophthalmol Clin 2021; 61:79-87. [PMID: 33743530 DOI: 10.1097/iio.0000000000000348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Glucocorticoids for Thyroid Eye Disease. Int Ophthalmol Clin 2021; 61:63-78. [PMID: 33743529 DOI: 10.1097/iio.0000000000000357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
BACKGROUND Dysthyroid optic neuropathy (DON) is a serious complication of Graves orbitopathy (GO) from optic nerve dysfunction that may result in permanent loss of vision. PURPOSE This paper reviews the current knowledge of DON, including its pathogenesis and epidemiology, clinical and radiologic features, and management choices and outcomes. METHODS Literature review and author retrospective case series. RESULTS Over 90% of DON cases are related to nerve compression by enlarged extraocular muscles (EOM) while the remainder are caused by stretching of the optic nerve without compression. DON's incidence is 5-8% of GO cases. Risk factors include advancing age, male gender, smoking and diabetes mellitus, and these cases should be referred promptly to an ophthalmologist or GO clinic to rule out DON and for ongoing care. Clinical features of DON may include reduction in central and colour vision (unexplained by other ocular disorders), afferent pupil defect and/or optic disc edema. Since most cases are associated with enlarged EOM, restricted motility and soft tissue venous congestion are common. Visual fields and optical coherence tomography (OCT) help confirm the diagnosis while CT or MRI Scans show apical optic nerve compression or proptosis with optic nerve stretch. Standard therapy includes iv/oral corticosteroids (CS) with partial response in most cases, but often relapse with tapering. Radiotherapy may delay or avoid surgery and may prevent the onset of DON when combined with CS in high-risk individuals. The benefits of newer biologic targeted therapy are not clear. Orbital decompression surgery often has positive outcomes, even in cases of severe vision loss or delayed surgery. The most common surgical complication is worsening strabismus, which may worsen visual function and quality of life. In rare cases, permanent vision loss from DON may occur despite full therapy. CONCLUSIONS Although DON may cause vision loss, most cases are reversible if recognized and managed in a timely manner.
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Affiliation(s)
- P J Dolman
- Department of Ophthalmology and Visual Sciences, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.
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26
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Lee SM, Im JH, Shin HS, Lew H. Clinical outcomes of hypofractionated radiotherapy for thyroid-associated ophthalmopathy. BJR Open 2020; 2:20200013. [PMID: 33178975 PMCID: PMC7583352 DOI: 10.1259/bjro.20200013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/04/2020] [Accepted: 08/11/2020] [Indexed: 11/05/2022] Open
Abstract
Objective To evaluate the safety and effectiveness of hypofractionated orbital radiotherapy applied in the treatment of thyroid-associated ophthalmopathy (TAO) patients. Methods Between 2014 and 2018, we retrospectively reviewed the cases of 28 patients with TAO. All patients underwent radiotherapy on both retroocular tissues and received an oral steroid. Patients were divided into two treatment groups: 14 patients received conventional fractionated radiotherapy (20 Gy in 10 fractions), and the second group of 14 patients received hypofractionated radiotherapy (20 Gy in five fractions). The clinical activity score (CAS), NOSPECS (No physical signs or symptoms, Only signs, Soft tissue involvement, Proptosis, Extraocular muscle signs, Corneal involvement, and Sight loss) classification, Hess screen test and binocular single vision (BSV) were evaluated to determine the response to treatment before and at 1 month after radiotherapy. Results There were no significant differences in any of the variables between the two treatment groups. In both groups, the CAS and NOSPECS score decreased significantly, and the range of extraocular muscle motility in Hess screen test and BSV improved significantly after radiotherapy (p < 0.05). There were no significant differences in CAS, NOSPECS score, Hess screen test or BSV between the two groups. No radiation-related, acute severe toxicity was observed. Conclusion Hypofractionated radiotherapy for TAO produced a comparable clinical outcome to that of conventional fractionated radiotherapy. Further case accumulation and long-term follow-up are required to determine if late toxicity occurs and to confirm efficacy. Advances in knowledge This is the first study to show that the efficacy and risk of adverse events are comparable between hypofractionated radiotherapy and conventional radiotherapy in the treatment of TAO.
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Affiliation(s)
- Sang Min Lee
- Department of Ophthalmology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Jung Ho Im
- Depratment of Radiation Oncology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Hyun Soo Shin
- Depratment of Radiation Oncology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Helen Lew
- Department of Ophthalmology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
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27
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Kim JY, Park S, Lee HJ, Lew H, Kim GJ. Functionally enhanced placenta-derived mesenchymal stem cells inhibit adipogenesis in orbital fibroblasts with Graves' ophthalmopathy. Stem Cell Res Ther 2020; 11:469. [PMID: 33153489 PMCID: PMC7643360 DOI: 10.1186/s13287-020-01982-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 10/20/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Placenta-derived mesenchymal stem cells (PD-MSCs) have unique immunomodulatory properties. Phosphatase of regenerating liver-1 (PRL-1) regulates the self-renewal ability of stem cells and promotes proliferation. Graves' ophthalmopathy (GO) is an autoimmune inflammatory disease of the orbit and is characterized by increased orbital levels of adipose tissue. Here, we evaluated the therapeutic mechanism for regulation of adipogenesis by PRL-1-overexpressing PD-MSCs (PD-MSCsPRL-1, PRL-1+) in orbital fibroblast (OF) with GO patients. METHODS PD-MSCs isolated from human placenta were transfected with the PRL-1 gene using nonviral transfection method. Primary OFs were isolated from orbital adipose tissue specimens from GO patients. After maturation as adipogenic differentiation, normal and GO-derived OFs were cocultured with naïve and PD-MSCsPRL-1. We analyzed the protein levels of adipogenesis markers and their signaling pathways in OFs from GO patients. RESULTS The characteristics of PD-MSCsPRL-1 were similar to those of naïve cells. OFs from GO patients induced adipocyte differentiation and had significantly decreased a lipid accumulation after coculture with PD-MSCsPRL-1 compared to naïve cells. The mRNA and protein expression of adipogenic markers was decreased in PD-MSCsPRL-1. Insulin-like growth factor-binding proteins (IGFBPs) secreting PD-MSCsPRL-1 downregulated the phosphorylated PI3K/AKT/mTOR expression in OFs from GO patients. Interestingly, IGFBP2, - 4, - 6, and - 7 expression in PD-MSCsPRL-1, which was mediated by integrin alpha 4 (ITGA4) and beta 7 (ITGB7), was higher than that in naïve cells and upregulated phosphorylated FAK downstream factor. CONCLUSION In summary, IGFBPs secreting PD-MSCPRL-1 inhibit adipogenesis in OFs from GO patients by upregulating phosphorylated FAK and downregulating PI3K/AKT/mTOR signaling pathway. The functional enhancement of PD-MSCs by nonviral gene modification provides a novel therapeutic strategy for the treatment of degenerative diseases.
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Affiliation(s)
- Jae Yeon Kim
- Department of Biomedical Science, CHA University, Seongnam, 13488, Republic of Korea
| | - Sohae Park
- Department of Biomedical Science, CHA University, Seongnam, 13488, Republic of Korea
| | - Hyun-Jung Lee
- Center for Non-Clinical Development, CHA Advanced Research Institute CHA University, Seongnam, 13488, Republic of Korea
| | - Helen Lew
- Department of Ophthalmology, CHA Bundang Medical Center CHA University, Seongnam, 13496, Republic of Korea
| | - Gi Jin Kim
- Department of Biomedical Science, CHA University, Seongnam, 13488, Republic of Korea.
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Nanda T, Sanchez A, Purswani J, Wu CC, Kazim M, Wang TJC. Contour Variability in Thyroid Eye Disease with Compressive Optic Neuropathy Treated with Radiation Therapy. Adv Radiat Oncol 2020; 5:804-808. [PMID: 33089016 PMCID: PMC7560569 DOI: 10.1016/j.adro.2020.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/11/2020] [Indexed: 12/03/2022] Open
Abstract
Purpose Few studies have evaluated the methodology by which radiation therapy (RT) for thyroid eye disease and compressive optic neuropathy is performed. The objective of this study was to retrospectively review our experience from a radiation planning standpoint and to determine whether current treatment methods provide adequate dose to target and collateral structures. Methods A retrospective review of 52 patients (104 orbits) with bilateral thyroid eye disease and compressive optic neuropathy treated with RT (20 Gy in 10 fractions) at our institution. RT plans were analyzed for target volumes and doses. Visual fields, color plates, and visual acuity were assessed pretreatment and at last available follow-up post RT. A standardized, anatomic contour of the retro-orbital space was applied to these retrospective plans to determine dose to the entire space, rather than the self-selected target structure. Results Compared with the anatomic retro-orbital space, the original contour overlapped by only 68%. Maximum and mean dose was 2134 cGy and 1910 cGy to the anatomic retro-orbital space. Consequently, 39.8% of the orbits had a mean dose <19 Gy (<17 Gy 16.4%, <18 Gy 27.6% <19 Gy 37.8%, <20 Gy 59.2%, 20-21 Gy 35.8%, >21 Gy 5%). There was no significant association of improvement in color plates (P = .07), visual fields (P = .77), and visual acuity (P = .62), based on these dose differences. When beam placement was retrospectively adjusted to include a space of 0.5 cm between the lens and the anterior beam edge, there was a 39.4% and 20.3% decrease in max and mean dose to the lens. Conclusions Without a standardized protocol for contouring in thyroid eye disease, target delineation was found to be rather varied, even among the same practitioner. Differences in dose to the anatomic retro-orbital space did not affect outcomes in the follow-up period. Although precise contouring of the retro-orbital space may be of little clinical consequence overall, a >0.5 cm space from the lens may significantly reduce or delay cataractogenesis.
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Affiliation(s)
- Tavish Nanda
- Columbia University Irving Medical Center Harkness Eye Institute, New York, New York
| | - Andrew Sanchez
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Juhi Purswani
- Department of Radiation Oncology, New York University, New York, New York
| | - Cheng-Chia Wu
- Department of Radiation Oncology, Columbia University Medical Center, New York, New York
| | - Michael Kazim
- Columbia University Irving Medical Center Harkness Eye Institute, New York, New York.,Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University Medical Center, New York, New York
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High-Dose Oral Methylprednisolone for the Management of Severe Active Thyroid Eye Disease During the Coronavirus Disease 2019 Pandemic. Ophthalmic Plast Reconstr Surg 2020; 36:418-419. [PMID: 32658134 DOI: 10.1097/iop.0000000000001787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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Davies TF, Andersen S, Latif R, Nagayama Y, Barbesino G, Brito M, Eckstein AK, Stagnaro-Green A, Kahaly GJ. Graves' disease. Nat Rev Dis Primers 2020; 6:52. [PMID: 32616746 DOI: 10.1038/s41572-020-0184-y] [Citation(s) in RCA: 168] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2020] [Indexed: 02/08/2023]
Abstract
Graves' disease (GD) is an autoimmune disease that primarily affects the thyroid gland. It is the most common cause of hyperthyroidism and occurs at all ages but especially in women of reproductive age. Graves' hyperthyroidism is caused by autoantibodies to the thyroid-stimulating hormone receptor (TSHR) that act as agonists and induce excessive thyroid hormone secretion, releasing the thyroid gland from pituitary control. TSHR autoantibodies also underlie Graves' orbitopathy (GO) and pretibial myxoedema. Additionally, the pathophysiology of GO (and likely pretibial myxoedema) involves the synergism of insulin-like growth factor 1 receptor (IGF1R) with TSHR autoantibodies, causing retro-orbital tissue expansion and inflammation. Although the aetiology of GD remains unknown, evidence indicates a strong genetic component combined with random potential environmental insults in an immunologically susceptible individual. The treatment of GD has not changed substantially for many years and remains a choice between antithyroid drugs, radioiodine or surgery. However, antithyroid drug use can cause drug-induced embryopathy in pregnancy, radioiodine therapy can exacerbate GO and surgery can result in hypoparathyroidism or laryngeal nerve damage. Therefore, future studies should focus on improved drug management, and a number of important advances are on the horizon.
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Affiliation(s)
- Terry F Davies
- Thyroid Research Laboratory, Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,James J. Peters VA Medical Center, New York, NY, USA. .,Mount Sinai Thyroid Center, Mount Sinai Downtown at Union Sq, New York, NY, USA.
| | - Stig Andersen
- Department of Geriatric and Internal Medicine and Arctic Health Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Rauf Latif
- Thyroid Research Laboratory, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,James J. Peters VA Medical Center, New York, NY, USA
| | - Yuji Nagayama
- Department of Molecular Medicine, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki, Japan
| | - Giuseppe Barbesino
- Thyroid Unit, Division of Endocrinology, Massachusetts General Hospital, Boston, MA, USA
| | - Maria Brito
- Mount Sinai Thyroid Center, Mount Sinai Downtown at Union Sq, New York, NY, USA
| | - Anja K Eckstein
- Department of Ophthalmology, University Duisburg Essen, Essen, Germany
| | - Alex Stagnaro-Green
- Departments of Medicine, Obstetrics and Gynecology and Medical Education, University of Illinois College of Medicine at Rockford, Rockford, IL, USA
| | - George J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Centre, Mainz, Germany
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Evolution of thyroid eye disease decompression-dysthyroid optic neuropathy. Eye (Lond) 2018; 33:206-211. [PMID: 30390053 DOI: 10.1038/s41433-018-0259-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 10/10/2018] [Indexed: 11/08/2022] Open
Abstract
Orbital decompression surgery and medical therapy for thyroid eye disease (TED) have evolved over the past 150 years and afforded the opportunity to restore pre-disease appearance and visual function. This manuscript explores the past 150 years of surgical innovation for the treatment of TED. The "Age of Surgical Heroism" spans the time from 1888 to 1979 during which the pioneers of orbital decompression developed lateral orbitotomy, transcranial decompression, paranasal sinus decompression, and transantral decompression despite an incomplete understanding of the pathophysiology of both TED and a limited ability to non-invasively assess their patients. The "Age of Surgical Refinement" dawned with the development of computed tomography and represents the years 1979-2000. During this time, the "swinging eyelid" approach for two- and three-wall decompressions was introduced, a combined orbital-extradural four wall decompression procedure was developed, fat decompression was explored, and endoscopic decompression techniques were advanced. At the beginning of the 21st century, our understanding of the orbital pathophysiology of TED evolved significantly. Clinicians recognized the age-related phenotype of TED based largely on the relative contribution of extraocular muscle enlargement vs. orbital fat expansion. The "Modern Age" of Customized Orbital Decompression features both "medical decompression" during the active phase of TED and, in the stable phase, customized surgical plans incorporating individual patients' anatomy, orbital pathology, and surgical goals that collectively maximize therapeutic benefit while minimizing therapeutic morbidity.
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Abstract
PURPOSE Dysthyroid optic neuropathy (DON) is a serious complication of Graves orbitopathy that can result in irreversible and profound visual loss. Controversy exists regarding the pathogenesis and management of the disease. The authors provide an overview of the current understanding of DON and present a therapeutic guideline. METHODS A review of the literature. RESULTS The mechanism of DON appears to be multifactorial: direct compression of the optic nerve by enlarged extraocular muscles, stretching of the optic nerve by proptosis, orbital pressure, vascular insufficiency, and inflammation. Some or all of these factors may be involved in an individual patient. There has only been one controlled trial comparing high-dose intravenous methylprednisolone to bony orbital decompression for DON. Both 2-wall and 3-wall decompression techniques successfully improve visual functions of patients with DON. There are few case reports/case series that suggest biologic agents may improve visual function in DON. CONCLUSIONS DON is a serious complication of Graves orbitopathy, the diagnosis and management of which is complex and requires a multidisciplinary approach. There is little evidence regarding the optimum management strategy. Based on the current literature, the first line of treatment is intravenous methylprednisolone, with the exact timing and indication of bony orbital decompression still to be determined. In addition, there may be a role for the use of biologic agents that will require a systematic program to determine efficacy.
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Abstract
PURPOSE To critically review the published literature on orbital radiotherapy as a treatment modality for thyroid eye disease (TED). METHODS A systematic review and analysis of the relevant published literature was performed. RESULTS Thyroid eye disease is an autoimmune condition that is amenable to treatments that modulate the immune response, including orbital radiotherapy (ORT). Ideal candidates for ORT are patients in the early, active phase of TED with moderate to severe, or rapidly progressive, disease, including patients with significant motility deficits and compressive optic neuropathy. Patients with progressive strabismus may also benefit. Patients with mild or inactive disease will not benefit from ORT when compared with the natural history of the disease. Orbital radiotherapy should generally be used in conjunction with corticosteroid therapy, with response to corticosteroids demonstrating the immunomodulatory therapeutic potential of ORT. When treating TED-compressive optic neuropathy, ORT may help obviate the need for urgent surgical decompression, or postpone it until the stable, inactive phase of the disease. Orbital radiotherapy treatment doses should approach 20 Gy in most cases, but lower doses may be considered in younger patients without significant dysmotility. The safety profile of ORT is well established, and side effects are minimal in appropriately selected patients. CONCLUSIONS Radiotherapy is a safe and effective treatment for active TED in appropriately selected patients.
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Gold KG, Scofield S, Isaacson SR, Stewart MW, Kazim M. Orbital Radiotherapy Combined With Corticosteroid Treatment for Thyroid Eye Disease-Compressive Optic Neuropathy. Ophthalmic Plast Reconstr Surg 2018. [PMID: 29517594 DOI: 10.1097/iop.0000000000001003] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the effectiveness of orbital radiotherapy (ORT) in the treatment of thyroid eye disease (TED)-compressive optic neuropathy. METHODS A retrospective review of patients with corticosteroid-responsive compressive optic neuropathy due to TED treated with ORT. Study was conducted in compliance with Health Insurance Portability and Accountability Act. One hundred four patients (163 orbits) with a mean age of 61.7 years met inclusion criteria. Seventy-four percent (77/104) were female, and 32.7% (34/104) were current or previous smokers. A total absorbed dose of 2000 cGy fractionated in 10 treatment doses over the course of 2 weeks was administered to the retroocular tissues according to a standard protocol. The primary end point was failure of ORT, defined as persistent optic neuropathy following completion of radiotherapy that mandated urgent orbital decompression surgery. RESULTS Ninety-eight of 104 (94%) patients or 152 of 163 (93.3%) orbits did not require orbital decompression surgery during the acute phase. Patients who responded successfully to ORT had similar improvements in visual acuity, color vision, Humphrey threshold visual field testing, and afferent pupillary defects compared with patients who failed ORT and underwent urgent decompression surgery. Only 36.7% of successfully treated patients ultimately underwent elective surgery, including orbital decompression, strabismus, or eyelid surgery, during the inactive phase of TED. CONCLUSIONS The data from this study, the largest retrospective review reported to date, supports the use of ORT in eyes with corticosteroid-responsive TED-compressive optic neuropathy. ORT may favorably alter the natural history of active-phase TED by preventing recurrent compressive optic neuropathy after withdrawal of corticosteroids.
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Affiliation(s)
| | - Stacy Scofield
- Department of Ophthalmology, Columbia University, New York, New York
| | - Steven R Isaacson
- Department of Ophthalmology, Columbia University, New York, New York
| | - Michael W Stewart
- Department of Ophthalmology, Columbia University, New York, New York
| | - Michael Kazim
- Department of Ophthalmology, Columbia University, New York, New York
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36
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Morin J, Dolman PJ. Challenges and developments in both surgical and non-surgical treatments for thyroid eye disease. EXPERT REVIEW OF OPHTHALMOLOGY 2018. [DOI: 10.1080/17469899.2018.1455501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Julie Morin
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Peter J. Dolman
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC, Canada
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Zhang S, Wang Y, Zhong S, Liu X, Huang Y, Fang S, Zhuang A, Li Y, Sun J, Zhou H, Fan X. Orbital radiotherapy plus three-wall orbital decompression in a patient with rare ocular manifestations of thyroid eye disease: case report. BMC Endocr Disord 2018; 18:7. [PMID: 29409479 PMCID: PMC5802057 DOI: 10.1186/s12902-018-0235-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 01/23/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thyroid eye disease (TED) is a debilitating autoimmune orbital disease that is often a result of Graves' disease. Dysthyroid optic neuropathy (DON) is a rare but sight-threatening manifestation of TED with therapeutic challenges that can potentially lead to visual loss. CASE PRESENTATION A 74-year-old man experienced active TED with extremely severe redness and swelling of the conjunctiva, loss of visual acuity and exacerbation of disfiguring proptosis. Computed tomography revealed the involvement of extraocular muscles resulting in optic nerve compression. He was in poor general condition and was intolerant to steroids. To achieve the optimal operating conditions for orbital decompression surgery, the patient was initially treated with orbital radiotherapy. The patient responded well, with improvements in clinical activity score and visual acuity. CONCLUSION This case demonstrates a rare and severe case of DON with therapeutic challenges. To date, no cases has been reported of a patient with such severe and unusual ocular manifestations. Early awareness of the occurrence of optic nerve compression and prompt treatment are important to prevent irreversible outcomes. Orbital radiotherapy should be considered as a useful surgery-delaying alternative for DON, especially in patients who have contraindications to steroids.
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Affiliation(s)
- Shuo Zhang
- Department of Ophthalmology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 ZhiZaoJu Road, Shanghai, 200011 China
| | - Yang Wang
- Department of Ophthalmology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 ZhiZaoJu Road, Shanghai, 200011 China
| | - Sisi Zhong
- Department of Ophthalmology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 ZhiZaoJu Road, Shanghai, 200011 China
| | - Xingtong Liu
- Department of Ophthalmology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 ZhiZaoJu Road, Shanghai, 200011 China
| | - Yazhuo Huang
- Department of Ophthalmology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 ZhiZaoJu Road, Shanghai, 200011 China
| | - Sijie Fang
- Department of Ophthalmology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 ZhiZaoJu Road, Shanghai, 200011 China
| | - Ai Zhuang
- Department of Ophthalmology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 ZhiZaoJu Road, Shanghai, 200011 China
| | - Yinwei Li
- Department of Ophthalmology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 ZhiZaoJu Road, Shanghai, 200011 China
| | - Jing Sun
- Department of Ophthalmology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 ZhiZaoJu Road, Shanghai, 200011 China
| | - Huifang Zhou
- Department of Ophthalmology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 ZhiZaoJu Road, Shanghai, 200011 China
| | - Xianqun Fan
- Department of Ophthalmology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 ZhiZaoJu Road, Shanghai, 200011 China
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Wang Y, Zhou H, Fan X. The effect of orbital radiation therapy on thyroid-associated orbitopathy complicated with dysthyroid optic neuropathy. Front Med 2017; 11:359-364. [PMID: 28500433 DOI: 10.1007/s11684-017-0528-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 02/08/2017] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Yang Wang
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
| | - Huifang Zhou
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China.
| | - Xianqun Fan
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China.
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Blandford AD, Zhang D, Chundury RV, Perry JD. Dysthyroid optic neuropathy: update on pathogenesis, diagnosis, and management. EXPERT REVIEW OF OPHTHALMOLOGY 2017; 12:111-121. [PMID: 28775762 DOI: 10.1080/17469899.2017.1276444] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Alexander D Blandford
- Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195
| | - Dalia Zhang
- Case Western Reserve University School of Medicine, 2109 Adelbert Road, Cleveland, OH 44106
| | - Rao V Chundury
- Eugene and Marilyn Glick Eye Institute, Indiana University, 1160 W Michigan St, Indianapolis, IN 46202
| | - Julian D Perry
- Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195
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Radiotherapy for the treatment of thyroid eye disease-a prospective comparison: Is orbital radiotherapy a suitable alternative to steroids? Ir J Med Sci 2017; 186:647-652. [PMID: 28050807 DOI: 10.1007/s11845-016-1542-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 12/25/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND AIMS To evaluate the efficacy of orbital radiotherapy (OR) for the treatment of thyroid eye disease (TED). METHODS Thirty-five consecutive patients with active TED with contraindications to steroid therapy received a course of OR. Bilateral retrobulbar irradiation was performed with a total dose of 20 Gy. 7-points clinical activity score (7-CAS), ocular motility, visual acuity (VA), exophthalmos and eyelid retraction were prospectively evaluated at 3, 6 and 12 months and compared with baseline data. RESULTS There was a statistically significant improvement in 7-CAS at 3, 6 and 12 months post-treatment (p < 0.05). Ocular motility disturbances improved at 6 and 12 months (p < 0.05). Visual acuity remained stable; there was no significant change in exophthalmos (mean 24 mm, SD 3 mm) or eyelid retraction (marginal reflex distance mean 6 mm, SD 1.5 mm) during the follow-up period. No side effects were registered. CONCLUSIONS This study suggests that OR might be effective in reducing 7-CAS and ocular motility disturbances. No significant improvement in proptosis or eyelid retraction should be expected from this treatment. OR might be considered a suitable alternative treatment in TED for patients who cannot tolerate steroids.
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41
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Weiler DL. Thyroid eye disease: a review. Clin Exp Optom 2016; 100:20-25. [PMID: 27701774 DOI: 10.1111/cxo.12472] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/27/2016] [Accepted: 07/16/2016] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Danielle L Weiler
- Optometry Section, Southern Arizona Veterans Affairs Health Care System, Tucson, Arizona, USA.,Southern California College of Optometry, Fullerton, California, USA
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Arenas M, Sabater S, Jiménez PL, Rovirosa À, Biete A, Linares V, Belles M, Panés J. Radiotherapy for Graves' disease. The possible role of low-dose radiotherapy. Rep Pract Oncol Radiother 2016; 21:213-8. [PMID: 27601953 DOI: 10.1016/j.rpor.2016.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 02/06/2016] [Indexed: 10/22/2022] Open
Abstract
Immunomodulatory effects of low-dose radiotherapy (LD-RT) have been used for the treatment of several benign diseases, including arthrodegenerative and inflammatory pathologies. Graves' disease is an autoimmune disease and radiotherapy (RT) is a therapeutic option for ocular complications. The dose recommended in the clinical practice is 20 Gy (2 Gy/day). We hypothesized that lower doses (<10 Gy total dose, <1 Gy/day) could results in higher efficacy if we achieved anti-inflammatory and immunomodulatory effects of LD-RT. We review current evidence on the effects of RT in the treatment of Graves' disease and the possible use of LD-RT treatment strategy.
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Affiliation(s)
- Meritxell Arenas
- Radiation Oncology Department, Hospital Universitari Sant Joan de Reus, Institut d'Investigacions Sanitàries Pere Virgili (IISPV), Universitat Rovira i Virgili (URV), Tarragona, Spain
| | - Sebastià Sabater
- Radiation Oncology Department, Complejo Hospitalario Universitario Albacete (CHUA), Spain
| | - Pedro Lara Jiménez
- Radiation Oncology Department, Hospital Universitario Dr Negrín, Universidad Las Palmas de Gran Canaria (LPGC), Las Palmas de Gran Canaria, Spain
| | - Àngels Rovirosa
- Radiation Oncology Department, Hospital Universitari Clínic de Barcelona, Spain
| | - Albert Biete
- Radiation Oncology Department, Hospital Universitari Clínic de Barcelona, Spain
| | - Victoria Linares
- Laboratory of Toxicology and Environmental Health, School of Medicine, IISPV, URV, Reus, Spain
| | - Montse Belles
- Laboratory of Toxicology and Environmental Health, School of Medicine, IISPV, URV, Reus, Spain
| | - Julià Panés
- Gastroenterology Department, Hospital Universitari Clínic de Barcelona, Spain
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Abstract
PURPOSE To review the current literature summarizing the state of knowledge on the use of orbital radiation therapy (ORT) in thyroid eye disease. METHODS A systematic review and analysis of the literature were performed. MEDLINE/PubMed, Cochrane Library databases, SCOPUS, and recent relevant journal articles were searched. RESULTS Thyroid eye disease is an autoimmune disorder that has the propensity to affect multiple orbital tissues and can cause permanent vision loss. In moderate to severe disease, treatment may be warranted and can include multiple therapeutic modalities. Orbital radiation therapy is frequently used in this setting and may act to break the inflammatory cycle of glycosaminoglycan production and deposition. There has been a wealth of data regarding the effectiveness of ORT in thyroid eye disease resulting in the publication of treatment algorithms and management guidelines; however, there continues to be a lack of conformity among experts on the exact role of ORT in thyroid eye disease. CONCLUSION The multiple different thyroid eye disease classification schemes and the concurrent use of other therapeutic modalities challenge the interpretation of studies evaluating the effectiveness of thyroid eye disease. Despite these limitations, the current literature indicates that ORT is generally safe and well tolerated. Orbital radiation therapy may have a modest effect on motility and proptosis early in the disease process. It is unclear whether ORT leads to improved quality of life. There are some data to support the use of ORT to prevent compressive optic neuropathy.
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Efficacy of combined orbital radiation and systemic steroids in the management of Graves' orbitopathy. Graefes Arch Clin Exp Ophthalmol 2016; 254:991-8. [PMID: 26876240 DOI: 10.1007/s00417-016-3280-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 01/14/2016] [Accepted: 01/20/2016] [Indexed: 10/22/2022] Open
Abstract
PURPOSE To compare the efficacy and safety of combination therapy with orbital irradiation and systemic steroids versus steroid monotherapy in the management of active Graves' orbitopathy (GO). METHODS The clinical charts of 127 patients with active inflammation due to GO who received intravenous steroid pulse therapy as a first-line treatment with or without orbital radiotherapy between 2010 and 2014 were reviewed. Patients were divided into two treatment groups: 1) combined orbital radiotherapy and steroid pulse therapy (SRT group) and 2) steroid pulse therapy only (ST group). Primary outcome measures included clinical activity score (CAS); NOSPECS classification; ocular motility impairment; and exophthalmos at 1, 3, 6, and 12 months after treatment. The secondary outcome measure was the change in orbital, extraocular muscle (EOM), and fat volume after treatment measured by orbit computed tomography. RESULTS Sixty-eight patients were included in the SRT group, and 59 patients were in the ST group. In both treatments, CAS and NOSPECS were significantly reduced. In the comparison of the degree of change from baseline between the groups, the SRT group demonstrated more improvement in NOSPECS and scores of ocular motility. Orbital, EOM, and fat volume significantly decreased in the SRT group; however, only fat volume was reduced in the ST group. Compressive optic neuropathy after treatment developed in 0 % of the SRT group and 3.4 % (2/59) of the ST group. Reactivation of inflammation occurred in 11.8 % (8/68) of the SRT group and 28.8 % (17/59) of the ST group. CONCLUSIONS Orbital radiotherapy in combination with steroid treatment significantly improved ocular motility by reducing EOM volume in patients with active GO.
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Radiation Therapy for Orbitopathy of Thyroid Eye Disease. Clin Ophthalmol 2016; 56:81-93. [DOI: 10.1097/iio.0000000000000098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Ettl A. Endokrine Orbitopathie. SPEKTRUM DER AUGENHEILKUNDE 2015. [DOI: 10.1007/s00717-015-0279-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Golnik KC. Neuro-Ophthalmology Annual Review. Asia Pac J Ophthalmol (Phila) 2015; 4:307-15. [PMID: 26417928 DOI: 10.1097/apo.0000000000000147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The purpose of this review was to update the practicing ophthalmologist on the English language neuro-ophthalmology literature from the past year. DESIGN A review of English language literature from August 1, 2013, to August 1, 2014, was conducted. METHODS The author searched PubMed from August 1, 2013, to August 1, 2014, limited to English language publications including original articles, review articles, and case reports and excluding letters to the editor, unpublished work, and abstracts. The following topics were searched: pupillary abnormalities, eye movement dysfunction, neuromuscular diseases, optic neuropathies, optic neuritis, demyelinating diseases including multiple sclerosis, lesions of the optic chiasm and posterior primary visual pathways, elevated intracranial pressure, tumors and aneurysms affecting the visual pathways, vascular diseases, higher visual function, and neuroimaging advances. The focus of this review is on clinically relevant literature in the past year for the practicing ophthalmologist. The aim was to highlight remarkable and interesting literature rather than exhaustively including all new neuro-ophthalmological publications of the year. RESULTS Initially, more than 11,000 articles were identified. One hundred were selected that met criteria specified above. CONCLUSIONS This review updates the comprehensive ophthalmologist on neuro-ophthalmic topics.
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Affiliation(s)
- Karl C Golnik
- From the Department of Ophthalmology, University of Cincinnati and the Cincinnati Eye Institute, Cincinnati, OH
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Graves' Ophthalmopathy: VISA versus EUGOGO Classification, Assessment, and Management. J Ophthalmol 2015; 2015:249125. [PMID: 26351570 PMCID: PMC4553342 DOI: 10.1155/2015/249125] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 07/22/2015] [Indexed: 01/07/2023] Open
Abstract
Graves' ophthalmopathy (GO) is an autoimmune inflammatory disorder associated with thyroid disease which affects ocular and orbital tissues. GO follows a biphasic course in which an initial active phase of progression is followed by a subsequent partial regression and a static inactive phase. Although the majority of GO patients have a mild, self-limiting, and nonprogressive ocular involvement, about 3–7% of GO patients exhibit a severe sight-threatening form of the disease due to corneal exposure or compressive optic neuropathy. An appropriate assessment of both severity and activity of the disease warrants an adequate treatment. The VISA (vision, inflammation, strabismus, and appearance), and the European Group of Graves' Orbitopathy (EUGOGO) classifications are the two widely used grading systems conceived to assess the activity and severity of GO and guide the therapeutic decision making. A critical analysis of classification, assessment, and management systems is reported. A simplified “GO activity assessment checklist” for routine clinical practice is proposed. Current treatments are reviewed and management guidelines according to the severity and activity of the disease are provided. New treatment modalities such as specific monoclonal antibodies, TSH-R antagonists, and other immunomodulatory agents show a promising outcome for GO patients.
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Vilar-González S, Lamas-Oliveira C, Fagúndez-Vargas MA, Núñez-Quintanilla AT, Pérez-Rozos A, Merayo-Lloves J, Escobar-Barranco JJ, Rico-Pérez JM. [Thyroid orbitopathy, an overview with special attention to the role of radiotherapy]. ACTA ACUST UNITED AC 2015; 62:188-99. [PMID: 25637365 DOI: 10.1016/j.endonu.2014.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 12/05/2014] [Accepted: 12/11/2014] [Indexed: 10/24/2022]
Abstract
Thyroid orbitopathy is the most prevalent non-thyroid symptom in Graves' syndrome. It has a high incidence and particularly affects young women. Smoking is clearly involved in its development and progress, and in its response to different treatments. This autoimmune condition usually has a benign course, independent from hyperthyroidism, but its severe, progressive forms represent a major therapeutic challenge. Clinical evaluation poses great difficulties, as there is no truly objective rating scale representing disease activity. New molecular or inflammation markers may prove to be useful in this regard. This review reports new findings about its pathophysiology and the different techniques used for treatment over time. Discussion particularly focuses on the immunomodulatory role of radiotherapy, as well as on its role together with corticosteroids.
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