Graves' ophthalmopathy: a rational approach to treatment

Approach to the Patient: Management and the Long-term Consequences of Graves' Disease in Children

In children, Graves' disease (GD) is the most common cause of hyperthyroidism. Most pediatric patients with GD will not go into lasting remission, even following many years of antidrug therapy. Thus, most pediatric patients will require radioactive iodine (RAI) or surgery. When antithyroid drugs are used, methimazole is the drug of choice. When methimazole is used in children, up to 20% will have minor adverse reactions and serious adverse events occur in up to 1%. RAI is an effective form of therapy when the thyroid size is less than 80 g. Because of concerns of whole-body radiation exposure, it is recommended that RAI be avoided in children under 5 years of age, and dosages less than 10 mCi be used between 5 and 10 years of age. Surgery is an effective treatment in children if performed by a high-volume thyroid surgeon. Because of the scarcity of high-volume pediatric thyroid surgeons, a multidisciplinary approach using pediatric surgeons and endocrine surgeons can be considered. Whereas there is a trend toward long-term antithyroid drug therapy in adults, for several reasons, this approach may not be practical for children. Determining the optimal treatment for the pediatric patient with GD, requires consideration of the risks and benefits relating to age and likelihood of remission.

Hemodynamic Instability during Thyroidectomy in Graves' Disease

BACKGROUND

The aim of this study was to investigate the changes in vital signs and hemodynamic status that occur in patients during the intraoperative course of thyroidectomy in Graves' Disease (GD).

METHODS

A total of 71 patients were included in the study. Patients were directed to surgery when they had large goiters with compressive symptoms or suspicious nodules, were pregnant or lactating, were unresponsive or intolerant to antithyroid drugs (ATDs), or expressed a preference to have surgery. All patients scheduled for operations underwent surgery while in the euthyroid state.

RESULTS

Hemodynamic instability was observed in 18 patients during thyroidectomy. Disease duration, sample weight, and thyroid-stimulating hormone receptor antibodies (TRAb) levels were found to be effective on hemodynamic instability. Logistic regression analysis revealed an 11-fold increase in the instability risk in patients with a period of disease shorter than 21 months (P = 0.037). A TRAb value >11.5 increased the risk by 235fold (p < 0.001).

CONCLUSION

High levels of TRAb values and new onset of disease with shorter periods of ATDs use may be risk factors for hemodynamic instability during thyroidectomy. Patients with larger thyroid glands are at greater risk for instability during surgery. Those risks should be taken into account during surgery, and the surgical and anesthetic management of the patient should be made more carefully in concordance with the anesthesia team.

ROLE OF MAGNETIC RESONANCE IMAGING IN THE ASSESSMENT OF ACTIVE THYROID-ASSOCIATED OPHTHALMOPATHY PATIENTS WITH LONG DISEASE DURATION

Objective: In thyroid-associated ophthalmopathy (TAO), long disease duration is negatively correlated with the response to immunosuppression treatment. The current treatment decision-making process does not involve magnetic resonance imaging (MRI); thus, we investigated the predictive value of MRI parameters for the immunosuppressive response in active moderate to severe TAO patients with different disease durations. Methods: We retrospectively analyzed the baseline MRI parameters of active TAO patients treated with guideline-recommended weekly glucocorticoid therapy in our center. Data were stratified by the quartile of disease duration. The signal intensity ratio (SIR) of T2-weighted images was used to describe the activity of extraocular muscles (EOMs). Results: Compared to the lowest quartile of disease duration, SIR values of EOMs were significantly lower in quartile 3 (Q3) and quartile 4 (Q4). Meanwhile, the clinical activity score (CAS) curve did not change in parallel and was not correlated with the SIR curve. In the highest quartile of disease duration, nonresponders had significantly lower SIR values of the most inflamed muscle (P = .03) and the medial rectus (P = .004) than did the responders, while no such significance was observed in patients within the lower 3 quartiles. A multivariable predictive model (including CAS, TAO duration, and SIR value) was established in each quartile. The fit of the model was better than CAS with regard to prognostic prediction and showed a high positive predictive value (Model 1: 86.67%; Model 2: 92.86%) and negative predictive value (Model 1: 88.89%; Model 2: 90%) in the top quartile. Conclusion: The anterior manifestation assessed by CAS is not always consistent with retro-orbital activity in long-term TAO patients. CAS is sufficient to reflect disease activity in short-term TAO patients. The supplementation of CAS with orbital MRI would be valuable in selecting appropriate active patients with a long disease duration. Abbreviations: AUC = area under the curve; CAS = clinical activity score; EOM = extraocular muscle; FT3 = free triiodothyronine; FT4 = free thyroxine; GC = glucocorticoid; ivGC = intravenous glucocorticoids; MRI = magnetic resonance imaging; NPV = negative predictive value; PPV = positive predictive value; SIR = signal intensity ratio; TAO = thyroid-associated ophthalmopathy; TRAb = thyroid-stimulating hormone receptor antibody; TSH = thyroid-stimulating hormone.

Orbital Radiotherapy Plus Concomitant Steroids in Moderate-to-Severe Graves' Ophthalmopathy: Good Results After Long-Term Follow-Up

BACKGROUND

Orbital radiotherapy (RT) is an effective and consolidate treatment for steroid-refractory Graves' ophthalmopathy (GO); however, long term effects are not well known.

OBJECTIVES

The aim of this study was to evaluate the long term efficacy and toxicity of orbital RT plus concomitant systemic steroids in a population of patients with moderate-to-severe GO or with eyesight threatening symptoms refractory to steroids.

METHODS

Forty patients with moderate-to-severe GO or with eyesight threatening symptoms not responsive/resistant to steroids were treated with orbital RT at the dose of 20 Gy in 10 fractions plus concomitant steroids. Clinical activity score (CAS) and symptoms status were evaluated to determine response to the treatment.

RESULTS

We reported overall improvement of symptoms, in particular, a regression at 1-year of diplopia in 32.5% eye movement impairment in 42.5%, eyesight in 27.5% and a 2 point reduction in CAS. After a median time of 56 months 21.9% of the patients underwent orbital decompression for relapse of GO, 4.8% received surgical correction of strabismus, and 2.4% received eyelid lipectomy. Acute toxicity was mild; grade 1 - 2 keratitis occurred in 19.5% of the patients and grade 3 keratitis was observed in 2.4% of the patients. Cataract occurred in 7.4% of the patients after a median time of 24-month-follow-up. No secondary malignancies were reported.

CONCLUSIONS

Our results reported the long-term efficacy and the good tolerance of orbital RT. The combination of RT plus steroids in this setting may avoid or delay performing the surgery in some cases.

Radiotherapy for the treatment of thyroid eye disease-a prospective comparison: Is orbital radiotherapy a suitable alternative to steroids?

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.

Radiotherapy for Graves' disease. The possible role of low-dose radiotherapy

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.

THERAPY OF ENDOCRINE DISEASE: Endocrine dilemma: management of Graves' orbitopathy

Management of Graves' orbitopathy (GO) must be based on the correct assessment of activity and severity of the disease. Activity is usually assessed with the Clinical Activity Score, whereas severity is classified according to a European Group On Graves' Orbitopathy (EUGOGO) consensus statement as mild, moderate-to-severe, and sight-threatening. Myopathic and chronic congestive forms are uncommon clinical presentations of GO. Restoration and maintenance of stable euthyroidism are recommended in the presence of GO.In moderate-to-severe disease, steroids have been widely employed and have shown to possess an anti-inflammatory activity, but about 20-30% of patients are not responsive and present recurrence. Some novel immunosuppressors have already been employed in clinical studies and have shown interesting results, although the lack of randomized and controlled trials suggests caution for their use in clinical practice. Potential targets for therapy in GO are the thyroid-stimulating hormone and the insulin-like growth factor 1 receptor on the fibroblasts, inflammatory cytokines, B and T cells, and the PIK3/mTORC1 signaling cascades for adipogenesis. A recent open study has shown that tocilizumab, an anti-sIL-6R antibody, inactivates GO. Consistent reports on the efficacy of rituximab have recently been challenged by randomized controlled trials.As the main goal of treatment is the well-being of the patient, the therapeutic strategy should be addressed to better suit the patient needs, more than improving one or more biological parameters. The increasing availability of new therapies will expand the therapeutic options for GO patients and allow the clinician to really personalize the treatment to better suit the patients' personal needs.

Compressive Optic Neuropathy and Repeat Orbital Decompression: A Case Series

PURPOSE

To characterize the presenting characteristics, preoperative clinical activity score (CAS), surgical approach, and visual outcomes in patients with thyroid eye disease undergoing repeat orbital decompression for recurrent or recalcitrant compressive optic neuropathy (CON).

METHODS

The medical records of patients with recurrent or recalcitrant CON undergoing repeat orbital decompressions were retrospectively reviewed. The primary outcome measures included pre- and postoperative Humphrey visual field mean deviation, visual acuity (VA) measured in logarithm of the minimal angle of resolution, color vision measured by Ishihara plates, and presence of relative afferent pupillary defect. Details of the surgical procedure and each patient's CAS at presentation were also recorded.

RESULTS

Six patients, 9 orbits, with a mean preoperative CAS of 3.8 were included in this review. The mean time between initial decompression and presentation to our center for recurrent or persistent CON symptoms was 8.6 years (range, 1 to 15 years). At presentation, the average Humphrey visual field mean deviation was -16.5 (standard deviation: 8.8), improving to -3.8 (2.4) postoperatively with a mean of 9.3 months follow up (mean improvement of 75%). Preoperative VA was 0.34 (0.23) LogMAR, improving to 0.05 (0.10) LogMAR with a mean follow up of 10.4 months. Pre- to postoperative comparisons of clinical measures all showed statistically significant improvement (p < 0.05). Eight eyes presented with decreased VA (any VA < 20/20), 4 with decreased color vision (any color vision < 11), and 1 with a relative afferent pupillary defect, and all these patients demonstrated improvement following repeat orbital decompression.

CONCLUSIONS

In patients with thyroid eye disease, symptoms of recurrent CON occurred up to 15 years following initial orbital decompression underscoring the smoldering, progressive nature of the disease. Repeat decompression that focused on the orbital apex resulted in visual improvement in all 6 patients. Despite clinical evidence of CON, the mean CAS of these patients at presentation was only 3.8, highlighting the importance of close monitoring of patients with thyroid eye disease following decompression regardless of the external manifestations of disease activity.

Total thyroidectomy as a method of choice in the treatment of Graves' disease - analysis of 1432 patients

Background

Graves’ disease represents an autoimmune disease of the thyroid gland where surgery has an important role in its treatment. The aim of our paper was to analyze the results of surgical treatment, the frequency of microcarcinoma and carcinoma, as well as to compare surgical complications in relation to the various types of operations performed for Graves’ disease.

Methods

We analysed 1432 patients (221 male and 1211 female) who underwent surgery for Graves’ disease at the Centre for Endocrine Surgery in Belgrade during 15 years (1996–2010). Average age was 34.8 years. Frequency of surgical complications within the groups was analyzed with nonparametric Fisher’s test.

Results

Total thyroidectomy (TT) was performed in 974 (68%) patients, and Dunhill operation (D) in 221 (15.4). Carcinoma of thyroid gland was found in 146 patients (10.2%), of which 129 (9%) were a microcarcinoma. Complication rates were higher in the TT group, where there were 31 (3.2%) patients with permanent hypoparathyroidism, 9 (0.9%) patients with unilateral recurrent nerve paralysis and 10 (1.0%) patients with postoperative bleeding. Combined complications, such as permanent hypoparathyroidism with bleeding were more common in the D group where there were 2 patients (0,9%), while unilateral recurrent nerve paralysis with bleeding was more common in the TT group where there were 3 cases (0,3%).

Conclusions

Frequency of complications were not significantly statistically different in relation to the type of surgical procedure. Total thyroidectomy represents a safe and efficient method for treating patients with Graves’ disease, and it is not followed by a greater frequency of complications in relation to less extensive procedures.

The Brazilian consensus for the diagnosis and treatment of hyperthyroidism: recommendations by the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism

INTRODUCTION

Hyperthyroidism is characterized by increased synthesis and release of thyroid hormones by the thyroid gland. Thyrotoxicosis refers to the clinical syndrome resulting from excessive circulating thyroid hormones, secondary to hyperthyroidism or due to other causes. This article describes evidence-based guidelines for the clinical management of thyrotoxicosis.

OBJECTIVE

This consensus, developed by Brazilian experts and sponsored by the Department of Thyroid Brazilian Society of Endocrinology and Metabolism, aims to address the management, diagnosis and treatment of patients with thyrotoxicosis, according to the most recent evidence from the literature and appropriate for the clinical reality of Brazil.

MATERIALS AND METHODS

After structuring clinical questions, search for evidence was made available in the literature, initially in the database MedLine, PubMed and Embase databases and subsequently in SciELO - Lilacs. The strength of evidence was evaluated by Oxford classification system was established from the study design used, considering the best available evidence for each question.

RESULTS

We have defined 13 questions about the initial clinical approach for the diagnosis and treatment that resulted in 53 recommendations, including the etiology, treatment with antithyroid drugs, radioactive iodine and surgery. We also addressed hyperthyroidism in children, teenagers or pregnant patients, and management of hyperthyroidism in patients with Graves' ophthalmopathy and various other causes of thyrotoxicosis.

CONCLUSIONS

The clinical diagnosis of hyperthyroidism usually offers no difficulty and should be made with measurements of serum TSH and thyroid hormones. The treatment can be performed with antithyroid drugs, surgery or administration of radioactive iodine according to the etiology of thyrotoxicosis, local availability of methods and preferences of the attending physician and patient.

Pediatric Graves' disease: management in the post-propylthiouracil Era

The most prevalent cause of thyrotoxicosis in children is Graves’ disease (GD), and remission occurs only in a modest proportion of patients. Thus most pediatric patients with GD will need treatment with radioactive iodine (RAI; ¹³¹I) or surgical thyroidectomy. When antithyroid drugs (ATDs) are prescribed, only methimazole (MMI) should be administered, as PTU is associated with an unacceptable risk of severe liver injury. If remission does not occur following ATD therapy, ¹³¹I or surgery should be contemplated. When ¹³¹I is administered, dosages should be greater than 150 uCi/gm of thyroid tissue, with higher dosages needed for large glands. Considering that there will be low-level whole body radiation exposure associated with ¹³¹I, this treatment should be avoided in young children. When surgery is performed near total or total-thyroidectomy is the recommended procedure. Complications for thyroidectomy in children are considerably higher than in adults, thus an experienced thyroid surgeon is needed when children are operated on. Most importantly, the care of children with GD can be complicated and requires physicians with expertise in the area.

A prospective, randomized trial of intravenous glucocorticoids therapy with different protocols for patients with graves' ophthalmopathy

BACKGROUND

For patients with active moderate-to-severe Graves' ophthalmopathy (GO), a course of 4.5 g iv glucocorticoids (GCs) is the recommended therapy. The weekly protocol is preferred because of the potential safety concerns with the daily protocol. However, evidence for the superiority of different administration protocols is lacking.

METHODS

We conducted a prospective, randomized trial to compare the efficacy and safety of two protocols of iv 4.5 g methylprednisolone in a total of 80 patients in our institute. The patients were randomized to receive iv methylprednisolone weekly or daily. The response rate (a composite response endpoint including lid width, soft tissue involvement, proptosis, intraocular pressure, Clinical Activity Score [CAS], diplopia, and visual acuity) was evaluated as the primary outcome, and adverse effects were recorded at each visit. GO-associated serum cytokines were measured.

RESULTS

We found a significantly greater response rate for the weekly protocol vs the daily protocol at the 12th week (76.92 vs 41.03%; P = .0025) and a similar response rate at the fourth week. Seven patients on the daily protocol worsened when tapering iv methylprednisolone to oral prednisone in the fourth week. Patients in both groups showed significant CAS response, and at the 12th week, patients on the weekly protocol showed a nonsignificant trend toward greater CAS response. Weekly protocol showed significant prolonged retreatment-free survival. Severe side effects were only observed in two cases, both of which were on the daily protocol. Furthermore, we observed sustained decreased levels of serum CXCL10 in the 12th week compared to the baseline level (P = .0009) in the patients on the weekly protocol.

CONCLUSIONS

The weekly protocol of iv methylprednisolone therapy is more efficient and safer than the daily protocol for patients with active moderate-to-severe GO.

Topical rebamipide treatment for superior limbic keratoconjunctivitis in patients with thyroid eye disease

PURPOSE

To evaluate efficacy of topical rebamipide for superior limbic keratoconjunctivitis (SLK) in patients with thyroid eye disease.

DESIGN

Retrospective, observational case series.

METHODS

Thirty-three eyes from 20 thyroid eye disease patients with SLK who received topical rebamipide (Mucosta ophthalmic suspension unit dose 2%; Otsuka Pharmaceutical Co, Ltd; chemical name, (2RS)-2-(4-chlorobenzoylamino)-3-(2-oxo-1, 2-dihydroquinolin-4-yl) propanoic acid) were included. The following items were evaluated before and 4 weeks after the start of treatments: presence or absence of SLK, rose bengal staining score, area and density classification of fluorescein staining, Schirmer test I results (without topical anesthesia), tear film break-up time, Hertel exophthalmometry values, and margin reflex distances 1 and 2.

RESULTS

Twenty-eight eyes showed complete disappearance of SLK after treatment (84.8%; P < .001). The other 5 eyes (15.2%) demonstrated significant improvement, but had residual punctate rose bengal staining and fluorescein staining near the superior corneal limbus. All 5 eyes exhibited at least 1 of the following findings: proptosis of more than 17.7 mm and upper or lower eyelid retractions or both. Incidence of upper eyelid retraction was significantly higher in eyes with SLK than in those without SLK at the 4-week follow-up (P = .021). The severity of rose bengal staining and fluorescein staining improved significantly after treatment (P < .001). Although the Schirmer test results remained constant before and after the treatment (P = .212), tear film break-up time increased significantly in the posttherapeutic state (P = .009). No serious adverse events were reported.

CONCLUSIONS

Topical rebamipide improved SLK in patients with thyroid eye disease, suggesting a first-line treatment in such patients.

Methotrexate for the treatment of thyroid eye disease

Background/Aim. To evaluate the efficacy of methotrexate for the treatment of thyroid eye disease (TED). Methods. 36 consecutive patients with active TED, previously treated with corticosteroids but stopped due to the occurrence of side effects, were commenced on methotrexate therapy. Two different weekly doses were administered depending on the weight of the patient (7.5 mg or 10 mg). Clinical activity score (7-CAS), visual acuity (VA), ocular motility, exophthalmos, and eyelid position were retrospectively 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 after treatment (P < 0.0001). There was no significant change in visual acuity. Ocular motility disturbances improved at 6 and 12 months (P < 0.001). There was no significant change in exophthalmos (mean 24 mm, SD 3 mm) or eyelid position (marginal reflex distance mean 6 mm, SD 1.5 mm) during the follow-up period. No side effects were registered. Conclusions. Methotrexate therapy is effective in reducing CAS and ocular motility disturbances. No significant improvement in proptosis or eyelid retraction should be expected from this treatment. Eventually, it might be considered a suitable alternative treatment in TED for patients who cannot tolerate steroids.

Graves' orbitopathy: imperfect treatments for a rare disease

Graves' orbitopathy (GO) is the most frequent and invalidating extrathyroidal expression of Graves' disease. Its incidence and prevalence are, however, low. About three quarters of Graves' patients have no GO at diagnosis, and moderate-to-severe and severe forms represent no more that 5-6% of cases. Progression to severe forms occurs rarely, but it may be caused by risk factors, the most important being smoking and poor control of thyroid dysfunction. Lot of progress has been recently achieved in the understanding of GO pathogenesis, while the disease remains a therapeutic challenge and dilemma. Common treatments for moderate-to-severe and active forms of GO (glucocorticoids and orbital radiotherapy) frequently provide incomplete responses and may be followed by relapse or progression of GO. After the disease has been inactivated by medical treatment, many patients need rehabilitative surgery for residual manifestations (orbital decompression for exophthalmos, squint surgery for extraocular muscle dysfunction, eyelid surgery for eyelid malposition). Novel pharmacological treatments are on the horizon and might target pathogenetic mechanisms of the disease better than glucocorticoids. Clinical evidence concerning their efficacy and safety is presently lacking.

Orbital decompression in thyroid eye disease

Though enlargement of the bony orbit by orbital decompression surgery has been known for about a century, surgical techniques vary all around the world mostly depending on the patient's clinical presentation but also on the institutional habits or the surgeon's skills. Ideally every surgical intervention should be tailored to the patient's specific needs. Therefore the aim of this paper is to review outcomes, hints, trends, and perspectives in orbital decompression surgery in thyroid eye disease regarding different surgical techniques.

The evaluation and treatment of graves ophthalmopathy

Optimum care of the patient with Graves ophthalmopathy (GO) is achieved through teamwork between the endocrinologist and ophthalmologist, with input from ancillary specialists as needed. Clinical evaluation should include determination of both the severity and the activity of the disease. It is important to assess early in the evaluation the impact of the disease on the patient's quality of life and their priorities and expectations regarding management. Once this information has been gathered, careful discussion between patient and physicians can define the management plan. This article reviews the pathophysiology, epidemiology, evaluation, and management of GO.

[Thyroid ophthalmopathy at the time of European Group On Graves Orbitopathy (EUGOGO)]

Thyroid ophthalmopathy is one of the features of auto-immune thyroid diseases. Exophtalmos is not the only sign of this affection and may even be absent in severe sight-threatening cases. All subjects with this ophtalmopathy should benefit from euthyroidism restoration, smoking withdrawal and local measures. Objective and repeated assessment should identify the mild and stable disease carrying a fair prognosis and therefore recognize without delay the other patients for whom an optimal management will be supported by a multidisciplinary and expert team. The treatment of choice for moderate-to-severe and active ophthalmopathy is intravenous glucocorticoids. Sight-threatening cases not rapidly alleviated by intravenous glucocorticoids warrant surgical decompression. Later on, surgery (orbital decompression, squint surgery, eyelid surgery, in this order) will eventually be needed for inactive disease.

The dilemma of how to manage Graves' hyperthyroidism in patients with associated orbitopathy

CONTEXT

Graves' orbitopathy (GO) is present in about 50% of patients with Graves' hyperthyroidism. It may range from mild to moderately severe and (rarely) to sight-threatening. Whether antithyroid drugs (ATDs), radioactive iodine (RAI), or thyroidectomy should be the treatment of choice in the presence of overt and active GO is a matter of debate.

EVIDENCE ACQUISITION

The major source of data acquisition included PubMed search strategies. Articles published in the last 30 yr were screened. Furthermore, the bibliographies of relevant citations and chapters of major textbooks were evaluated for any additional appropriate citation.

EVIDENCE SYNTHESIS

Prompt restoration and stable maintenance of euthyroidism is important for the course of GO. ATDs and thyroidectomy per se do not influence the natural history of GO. RAI can cause progression or de novo development of GO, particularly in smokers. This effect can be prevented by oral steroid prophylaxis. In patients with mild orbitopathy, the choice of thyroid treatment is largely independent of GO. Moderate-to-severe and active GO should be treated without delay. Whether in these patients, concomitant treatment of hyperthyroidism should be conservative (ATDs) or ablative (RAI, thyroidectomy, or both) is presently based on expert opinion rather than evidence. Emerging and potentially interesting biological agents, such as rituximab, counteracting pathogenic mechanisms of both hyperthyroidism and GO, need to be evaluated in randomized clinical trials.

CONCLUSIONS

The choice of the optimal treatment for hyperthyroidism in patients with moderate-to-severe and active GO remains unsettled and is mainly based on personal experience. Randomized clinical trials in this field are eagerly needed.

Treatment of thyroid-associated orbitopathy with rituximab--a novel therapy for an old disease: case report and literature review

OBJECTIVE

To report the use of rituximab to treat thyroid-associated orbitopathy (TAO) in a patient with a concomitant B-cell organ-specific autoimmune disorder-the stiff person syndrome (SPS).

METHODS

We present a case report and a review of the related literature.

RESULTS

A 62-year-old man with SPS, latent autoimmune diabetes of the adult, and Graves-Basedow disease was referred to our medical center because of bilateral TAO. An ophthalmologic examination documented asymmetric bilateral NOSPECS (N = no signs or symptoms; O = only signs, no symptoms; S = soft tissue involvement; P = proptosis; E = extraocular muscle involvement; C = corneal involvement; and S = sight loss) class IV TAO (left eye>right eye) with a clinical activity score of 5 on a scale of 7. Magnetic resonance imaging of the orbits documented bilateral exophthalmos (left eye>right eye) due to retrobulbar fibroadipose infiltration, bilateral increase of extrinsic ocular muscle thickness, and enhancement of the left inferior rectus muscle on T2-weighted sequences. Because of concomitant incapacitating SPS and diet-controlled latent autoimmune diabetes of the adult, we excluded long-term corticosteroid therapy as an option and considered the use of rituximab, a mouse-human chimeric monoclonal antibody targeting the CD20 protein on pre-B and mature B lymphocytes. Rituximab was administered in accordance with the protocol for rheumatoid arthritis. During the subsequent 4 months, clinical signs and symptoms of TAO dramatically resolved (clinical activity score = 0 of 7) with a sustained improvement of the spastic paraparesis. The glutamic acid decarboxylase antibody titer remained high, and glycemic control and first-phase insulin secretion did not change.

CONCLUSION

Treatment of active TAO with rituximab should be considered when standard intravenous pulse glucocorticoid treatment is contraindicated or ineffective and when SPS or other organ-specific autoimmune disorders with involvement of humoral autoimmunity are present, inasmuch as more than 1 disease may benefit from the use of this chimeric monoclonal antibody.

The impact of bodily change on social behaviour in patients with thyroid-associated ophthalmopathy

Thyroid-associated ophthalmopathy (TAO) is characterized by the altered appearance of face and eyes and changed visual function. TAO has been described as alarming and crippling. It is well documented that TAO influences the patient's quality of life negatively. However, little is known about how the bodily change complicates the patient's social behaviour in everyday situations. The aim of this study was to explore how social behaviour is influenced by the bodily change and what it means to patients with TAO. An ethnographic study was conducted using in-depth interviews and participant observation. A total of 13 patients, nine women and four men, diagnosed with moderate to severe TAO were included. Data analysis was performed concurrently using grounded theory technique. The local ethics committee approved the study, and all participants gave written informed consent. The study reveals that the experience of bodily change had considerable consequences for patients' involvement with people and maintenance of social relations. Uncontrollable eyes were the dominating experience. It contained four sub-themes; the experience of changed facial communication, the experience of being somebody else, the experience of being clumsy among others and the experience of being cut off from the outside world. The bodily change affected people's attitude and behaviour towards them and their own ways of being with people. They struggled to change social behaviour and avoid withdrawal. In their struggle, they used seven different coping strategies. The study contributes to clarification of essential aspects of living with TAO. The condition of uncontrollable eyes may have serious consequences for patients' social behaviour and relationships with others. Early identification of the impact of bodily change and planned support may help prevent serious quality of life change.

Human TSH receptor ligands as pharmacological probes with potential clinical application

The biologic role of thyroid-stimulating hormone (TSH; thyrotropin) as an activator (agonist) of the TSH receptor (TSHR) in the hypothalamic-pituitary-thyroid axis is well known and activation of TSHR by recombinant human TSH is used clinically in patients with thyroid cancer. TSHR ligands other than TSH could be used to probe TSHR biology in thyroidal and extrathyroidal tissues, and potentially be employed in patients. A number of different TSHR ligands have been reported, including TSH analogs, antibodies and small-molecule, drug-like compounds. In this review, we will provide an update on all these classes of TSHR agonists and antagonists but place emphasis on small-molecule ligands.

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

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

Development of criteria for evaluating clinical response in thyroid eye disease using a modified Delphi technique

OBJECTIVE

To identify components of a provisional clinical response index for thyroid eye disease using a modified Delphi technique.

METHODS

The International Thyroid Eye Disease Society conducted a structured, 3-round Delphi exercise establishing consensus for a core set of measures for clinical trials in thyroid eye disease. The steering committee discussed the results in a face-to-face meeting (nominal group technique) and evaluated each criterion with respect to its feasibility, reliability, redundancy, and validity. Redundant measures were consolidated or excluded.

RESULTS

Criteria were parsed into 11 domains for the Delphi surveys. Eighty-four respondents participated in the Delphi 1 survey, providing 220 unique items. Ninety-two members (100% of the respondents from Delphi 1 plus 8 new participants) responded in Delphi 2 and rated the same 220 items. Sixty-four members (76% of participants) rated 153 criteria in Delphi 3 (67 criteria were excluded because of redundancy). Criteria with a mean greater than 6 (1 = least appropriate to 9 = most appropriate) were further evaluated by the nominal group technique and provisional core measures were chosen.

CONCLUSIONS

Using a Delphi exercise, we developed provisional core measures for assessing disease activity and severity in clinical trials of therapies for thyroid eye disease. These measures will be iteratively refined for use in multicenter clinical trials.

Repeated peribulbar injections of triamcinolone acetonide: a successful and safe treatment for moderate to severe Graves' ophthalmopathy

PURPOSE

In this study, we aimed to evaluate the efficacy of peribulbar triamcinolone injections to treat inflammatory signs of Graves' ophthalmopathy (GO) in patients with moderate to severe GO and associated optic neuropathy (ON).

METHODS

Twenty-one patients with active GO [clinical activity score (CAS) > or = 4] and systemic thyroid disease under control were enrolled in this prospective pilot study. Peribulbar triamcinolone acetonide was injected in each orbit (42 eyes), in four doses of 20 mg at 2-week intervals. Ophthalmological examination including CAS evaluation, visual field, computerized tomography (CT) scan and digital photography were performed before and after treatment.

RESULTS

Twenty-one patients (11 with moderate disease, 10 with ON) were enrolled in this study and followed for at least 14 months. Initial mean CAS was 6.38 +/- 1.49, which dropped to 1.8 +/- 1.12 after 6 months of treatment (P = 0.01; mean difference of 4.57 +/- 1.56; range 1-8 score points). ON was diagnosed in 10 patients. Of these, 66% improved with peribulbar triamcinolone exclusively. A transitory increase in intraocular pressure in two patients was controlled with topic medication.

CONCLUSION

Peribulbar triamcinolone injections reduce the inflammatory signs of moderate GO, as measured by the CAS, and could also be used as an alternative treatment for ON. Randomized clinical trials are needed to compare the results of triamcinolone peribulbar injections to those of other treatment modalities.

Exophthalmometry values of Turkish adult population and the effect of age, sex, refractive status, and Hertel base values on Hertel readings

PURPOSE

To establish normal exophthalmometry values in the adult Turkish population, and the impact of age, gender, interpupillary distance, Hertel base selection, and refractive status on globe position.

METHODS

Exophthalmometry measurements and refractive status of 2477 subjects were conducted in one tertiary and five primary health care centers. Change of globe position by age, intersex differences in terms of globe position, correlations of Hertel base with exophthalmometry results, and interpupillary distance (IPD) were evaluated. Multiple linear regression analysis was performed to test determination effect of each variable on final Hertel reading.

RESULTS

Median Hertel reading was 13 mm, and 95% of the population had an upper limit of 17 mm for both eyes. There was a negative correlation between spherical equivalent of refractive status and exophthalmometry results and a weak positive correlation between IPD and exophthalmometry result. Mean Hertel value was found to decrease significantly after the third decade. Hertel base value was found to have moderate linear correlation with Hertel results. A weak correlation was detected with Hertel base/IPD ratio with final Hertel results. Multiple linear regression analysis was performed and only 13% and 20% of change in Hertel values bilaterally were found to be determined by other variables (age, IPD, refractive status, and Hertel base value) for females and males.

CONCLUSIONS

Normative dataset for exophthalmometry results of the Turkish population is established to be used in clinical practice and research. Only 13% to 20% of change in Hertel values was detected to be determined by age, IPD and Hertel base values.

Determinants of liver damage associated with intravenous methylprednisolone pulse therapy in Graves' ophthalmopathy

BACKGROUND

Intravenous methylprednisolone pulses (IVMP) are more efficacious and better tolerated than oral prednisone in Graves' ophthalmopathy (GO) patients. However, acute and severe liver damage has been reported in sporadic cases during IVMP, resulting in fatal acute liver failure in four patients so far. The mechanism causing the liver damage is incompletely understood.

DESIGN

We performed a prospective observational study in 13 patients with dysthyroid optic neuropathy (group A) and in 14 patients with moderately severe GO (group B) who were treated with high-dose (group A) or low-dose (group B) IVMP; cumulative steroid doses were 8.45 g in group A and 4.5 g in group B, and follow-up time was 24 weeks.

MAIN OUTCOME

Slight increases in serum aminotransferases (in alanine aminotransferase [ALAT] more than in aspartate aminotransferase [ASAT]) were observed, in seven patients exceeding the upper normal limit of 40 U/L. These changes were more prominent in group A than in group B as was also evident from a decrease in ASAT/ALAT ratio in group A but not in group B. Changes in serum aminotransferases occurred especially in the first 6 weeks of IVMP, becoming smaller thereafter with the decrease in steroid dosage. Pretreatment liver steatosis or diabetes were not related to liver damage, but preexistent viral hepatitis was.

CONCLUSION

IVMP in GO patients causes dose-dependent liver damage by a direct toxic effect of glucocorticoids on hepatocytes. Nevertheless, IVMP seems to be pretty safe if cumulative doses exceeding 8 g are avoided and liver function is checked before and at regular intervals during pulse therapy.

Viral conjunctivitis interfering with the clinical activity score and management of thyroid ophthalmopathy

INTRODUCTION

The management of Graves' ophthalmopathy is shared between endocrinologists and ophthalmologists. Assessment and treatment of the active inflammatory stage is based on the clinical activity and disease severity scores, often without detailed eye examination by the treating endocrinologist.

MATERIALS AND METHODS

We report a case of acute viral keratoconjunctivitis occurring during immunosuppressive treatment for Graves' ophthalmopathy which masked the signs, symptoms and response to treatment of the orbitopathy, posing a differential diagnostic challenge.

RESULTS

The apparent worsening of the ophthalmopathy and the increased clinical activity score led the treating endocrinologist to alter the management decisions. Ophthalmic examination confirmed the diagnosis of viral keratoconjunctivitis and immunosuppressive treatment was continued with significant final improvement of Graves' ophthalmopathy.

DISCUSSION

Ocular surface conditions, unrecognised by the treating physician, may complicate the assessment of thyroid ophthalmopathy when detailed eye examination is not performed. The diagnostic challenge of Graves' ophthalmopathy requires a combined approach by an endocrinologist and an ophthalmologist working as a team.

Smoking delays the response to treatment in episcleritis and scleritis

PURPOSE

To evaluate the influence of smoking on comorbidity, treatment, visual and general outcome in patients with scleritis.

METHODS

The smoking habits of 103 patients with a diagnosis of episcleritis or scleritis were evaluated. These patients were treated by one ruling protocol at the Leiden University Medical Center between 1997 and 2000. Medical records of each patient were evaluated in detail. Data on possible factors concerning smoking were collected by postal questionnaire.

RESULTS

Of all 103 patients diagnosed with either episcleritis or scleritis, 41 (39.8%) were smoking during treatment of the scleral inflammation. In total, 19 patients (18.4%) had a smoking history while 43 (41.7%) patients have never smoked. The response to any of the given medications could be delayed by at least 4 weeks in many smoking patients (odds ratio (OR) 5.4 [95% confidence interval 1.9-15.5]), particularly those with posterior scleritis. Smoking patients above the age of 48 years were even more likely to respond belatedly to any given therapy (OR 6.6 [2.1-20.7]). However, having a smoking history did not delay the response. Furthermore, smoking did not worsen the visual prognosis and was not associated with additional recurrences or ocular complications after successful treatment.

CONCLUSIONS

Although scleritis patients who smoked during treatment eventually responded, there was frequently over a month's delay before the medication became effective when compared to nonsmokers. This was irrespective of the type of disease or given therapy. As a consequence, smokers required more intensive therapy than those who did not smoke.

Infliximab: a novel treatment for sight-threatening thyroid associated ophthalmopathy

We describe a patient with sight threatening thyroid associated ophthalmopathy (TAO) who was successfully treated with infliximab, an anti-tumour necrosis factor (TNF)-a antibody.

The philosophy of Graves' ophthalmopathy

When asked what has been my philosophy of Graves' ophthalmopathy in the last 25 years in the process of caring for patients with this disease and doing clinical research, I identified in hindsight three major guiding principles. The first is a multidisciplinary approach to the disease. A close collaboration between internists and ophthalmologists and the institution of combined thyroid-eye clinics definitely improves patient care. It also creates a favorable environment for research, allowing one, for example, to do randomized clinical trials. The second is involvement of the patients themselves. This has been of great benefit. Contact with patient support groups, which are experts by experience, add a dimension not readily provided by physicians. Patients assisted in the development of a disease-specific quality-of-life questionnaire (the GO-QOL), which can be used as a separate outcome measurement of therapeutic interventions. The third is attention to the possibility of preventing the disease. Smoking has been identified as a major factor in Graves' ophthalmopathy, and there exists good circumstantial evidence that refraining from smoking has preventive value in every stage of the disease. The challenge for the future will be to identify Graves' hyperthyroid patients at high risk for the development of ocular pathology, thus allowing preventive intervention, and to design more effective therapeutic interventions once the disease has become clinically manifest.

The clinicopathologic basis of Graves' ophthalmopathy: a review

PURPOSE

Graves' ophthalmopathy (GO) is a controversial disease, with disagreement within the medical community regarding its pathogenesis, diagnosis, and treatment.

METHODS

We reviewed recent literature on clinical and pathological aspects of GO from both the endocrinologist's and ophthalmologist's perspective.

RESULTS

Investigations into the pathogenesis of GO have included possible antigenic targets, orbital cell types, and development of animal models. Diagnosis has been improved recently with new tools and grading systems, but can be complicated by conditions that may simulate one or more of the findings of GO. The new findings of clinical studies also compel practitioners to reassess commonly used GO treatments such as orbital irradiation.

CONCLUSIONS

Improved understanding of the pathogenic mechanisms of GO should hopefully lead to new diagnostic and therapeutic approaches to this problematic condition.

Should total thyroidectomy become the preferred procedure for surgical management of Graves' disease?

This study aims to evaluate our institution's experience with thyroidectomy for Graves' disease, with an emphasis on indications and long-term outcomes. The study cohort consisted of 103 patients (mean age 34.3 [+/-13.9] years), who underwent thyroidectomy for Graves' disease between 1991 and 2002. Clinical and follow-up data were obtained by retrospective review of medical records and by contacting treating physicians or patients. The most common surgical indications were patient preference (26%), cold nodule (24%), eye symptoms (20%), large goiter size (18%), allergy to antithyroidal medications (15%), and age younger than 16 years (14%). Thyroidectomies performed included 45 (total or near-total), 57 subtotal, and 1 lobectomy. Transient complications included hypocalcemia in 42 patients, and recurrent laryngeal nerve palsy in 5 patients. There was no difference in the frequency of hypocalcemia in patients undergoing total or subtotal resections. One patient developed permanent hypocalcemia and 2 permanent recurrent laryngeal nerve (RLN) injury. Only 3 patients who underwent subtotal resections remain off thyroxine and 2 developed recurrent hyperthyroidism approximately 17 and 54 months after surgery. Subtotal thyroidectomy is associated with a high rate of hypothyroidism and large remnants have potential for recurrence. Total or near-total thyroidectomy obviates these disadvantages and can be performed without increased complication rates, thus appearing to be the preferred extent of thyroidectomy for Graves' disease.

Thyroid-associated ophthalmopathy: a practical guide to classification, natural history and management

Thyroid-associated ophthalmopathy (TAO) is an autoimmune disorder that can be divided into three clinical subtypes: congestive, myopathic and mixed ophthalmopathy. It is probably caused by immune cross-reactivity between orbital and thyroid antigens. The best candidate antigens are the thyrotropin receptor and the novel protein, G2s, which is now identified as a fragment of the winged helix transcription factor, FOXP1. The relationship between radioiodine therapy and TAO is controversial, with two randomised controlled trials showing a transient worsening of the eye disease after treatment. The diagnosis of TAO is a clinical one, based on the presence of specific symptoms and signs. Orbital imaging, preferably magnetic resonance imaging, is useful when the diagnosis is in doubt and in patients with suspected optic neuropathy who may benefit from early intervention. Despite their lack of specificity, orbital antibodies may add weight to the diagnosis and may potentially be a useful tool in classifying the different subtypes of TAO and in monitoring disease activity. While antibodies against G2s and the thyrotropin receptor are seen in all subtypes, those against Fp and collagen XIII may be associated with the myopathic and congestive subtypes, respectively, where Fp is the flavoprotein subunit of the mitochondrial enzyme, succinate dehydrogenase. In most patients, TAO is self-limiting and no specific treatment is required. When treatment is indicated, glucocorticoids are the mainstay of therapy. Orbital radiotherapy improves the efficacy of glucocorticoids, but is probably less beneficial as monotherapy. Orbital surgery is best reserved for patients with 'burnt out' inactive disease, but urgent orbital decompression may be required for optic neuropathy. The severity and clinical activity of TAO are important in determining the need for specific treatment and the likelihood of success with medical therapy, respectively.

Ophthalmological evaluation in thyroid-associated ophthalmopathy

PURPOSE

Thyroid-associated ophthalmopathy (TAO) is an autoimmune disorder associated with Graves' disease and can seriously decrease quality of life. Current therapeutic regimens have considerable side-effects and are not always able to restore normal function and appearance. Timing and a proper choice of therapy are critical but require careful patient evaluation. The present paper aims to describe clinical symptoms and signs of TAO and their relevance for management.

RESULTS AND CONCLUSIONS

Thyroid-associated ophthalmopathy has an initial active inflammatory phase which usually lasts for 6-24 months but which may not infrequently continue for several years. The severity of the subsequent clinical manifestations is determined by the degree of optic nerve involvement, corneal involvement, eye muscle dysfunction and exophthalmus, and also by the degree of subjective illness and disfigurement. Disease severity is the key determinant of indication for therapy, while inflammatory activity is the key determinant of therapeutic choice. Immunosuppressive therapy may be used in the inflammatory stage, while reconstructive surgery should be postponed to the inactive phase. Emergency surgery may be needed for vision-threatening situations during the active stage.