Age Influences the Severity of Graves' Ophthalmopathy

[Graves' orbitopathy as the cause of diplopia in old age-Differences between young and old]

BACKGROUND

Endocrine orbitopathy (EO) is an autoimmune disease mostly associated with a disease of the thyroid gland, which leads to inflammation, adipogenesis and fibrosis. The severity of EO can vary greatly between individuals, which makes it difficult to exactly predict the natural course of the disease; however, this is important to be able to individually adapt the treatment. The aim of this study was to compare the clinical features, course, treatment and prognosis for patients with EO under 50 years old with older patients. The results of the study with a focus on motility are presented in this special issue.

PATIENTS AND METHODS

The hospital records of a randomly selected sample of 1000 patients from the EO databank in Essen (GODE), which includes 4260 patients, were analyzed. The patients were divided into two groups: group 1 ≤50 years and group 2 >50 years. Only patients with complete data sets were included in the statistical analyses.

RESULTS

Younger patients (n = 484) presented significantly more frequently with milder EO (53% vs. 33%, p < 0.0001), whereas older patients (n = 448) more frequently suffered from moderate or severe forms (44% vs. 64%, p < 0.0001). Older patients showed more severe strabismus, motility and clinical activity scores (5.9 vs. 2.3 prism diopters, PD/310° vs. 330°, both p < 0.0001, CAS 2.1 vs. 1.7, p = 0.001). Proptosis and the occurrence of optic nerve compression showed no significant differences between the groups (3% each). Multiple logistic regression showed that the necessity for a second eye muscle surgery was most strongly associated with a previous decompression (OR = 0.12, 95 % CI 0.1-0.2, p < 0.0001), followed by orbital irradiation and age.

CONCLUSION

In summary, younger patients with EO presented with milder clinical features, such as a lower rate of restrictive motility disorders and weaker expression of signs of inflammation. Therefore, older patients needed steroids, irradiation, eyelid and eye muscle surgery more frequently; however, the risk of dysthyroid optic neuropathy and the necessity of a second eye surgery were not or only slightly associated with age.

How Age Affects Graves' Orbitopathy-A Tertiary Center Study

PURPOSE

Graves' orbitopathy (GO) is an autoimmune disorder leading to inflammation, adipogenesis, and fibrosis. The severity of GO can vary widely among individuals, making it challenging to predict the natural course of the disease accurately, which is important for tailoring the treatment approach to the individual patient. The aim of this study was to compare the clinical characteristics, course, treatment, and prognosis of GO patients under 50 years with older patients.

METHODS

We reviewed the medical records of a random sample of 1000 patients in our GO database Essen (GODE) comprising 4260 patients at our tertiary referral center. Patients were divided into two groups: Group 1 (≤50 years) and Group 2 (>50 years). Only patients with a complete data set were included in the further statistical analysis.

RESULTS

The results showed that younger patients (n = 484) presented significantly more often with mild GO (53% vs. 33%, p < 0.0001), while older patients (n = 448) were more likely to experience moderate-to-severe disease (44% vs. 64%, p < 0.0001). Older patients showed more severe strabismus, motility, and clinical activity scores (5.9 vs. 2.3 PD/310° vs. 330° both p < 0.0001, CAS: 2.1 vs. 1.7, p = 0.001). Proptosis and occurrence of dysthyroid optic neuropathy (DON) showed no significant difference between groups (both 3%). Multiple logistic regression revealed that the need for a second step of eye muscle surgery was most strongly associated with prior decompression (OR = 0.12, 95% CI: 0.1-0.2, p < 0.0001) followed by orbital irradiation and age. The model showed good fitness regarding the area under the curve (AUC = 0.83).

DISCUSSION

In conclusion, younger GO patients present with milder clinical features such as a lower rate of restrictive motility disorders and less pronounced inflammatory signs. Therefore, older patients tend to need more steroids, irradiation, and lid and eye muscle surgery. Still, the risk of DON and the necessity of secondary eye muscle surgery are not or only slightly associated with age, respectively.

Characteristics of Graves' disease in children and adolescents in Nanjing: A retrospective investigation study

Objective

This cross-sectional study analyzed the clinical characteristics of newly diagnosed Graves' disease (GD) in children and adolescents to provide clinical evidence for the early diagnosis of GD.

Method

From 2013 to 2019, information on children and adolescents with newly diagnosed GD admitted to the Department of Endocrinology, Children's Hospital of Nanjing Medical University, was collected, including clinical features and laboratory tests. The data were summarized and statistically analyzed.

Result

This study included 204 cases of newly diagnosed GD, with 158 females and 46 males. The average age at initial diagnosis was 8.9 ± 2.9 years. A total of 132 cases (64.7%) had symptoms before puberty, and 72 cases (35.3%) had symptoms during puberty. Goiter was detected in 193 cases (94.6%). There were 140 cases (68.6%) of exophthalmos, and 21.4% (30/140) were infiltrative. At initial diagnosis, 10 cases (4.9%) reported leukopenia, 18 cases (8.8%) reported neutropenia, and 15 cases (7.4%) reported mild anemia. There was 1 (0.5%) case of thrombocytopenia and 1 (0.5%) case of agranulocytosis. Fifty-four cases (26.5%) had impaired liver function.

Conclusion

GD is more common in female children and adolescents. Parents may ignore their children's hypermetabolic symptoms in the early stages of GD. Routine blood and liver function tests are recommended at initial diagnosis to exclude abnormal hemogram and liver function.

Evaluation of Microcirculation in Optic Nerve Head Using Laser Speckle Flowgraphy in Active Thyroid Eye Disease

Background

Laser speckle flowgraphy (LSFG) can be used to estimate optic nerve blood flow. This study used LSFG to evaluate optic nerve microcirculation in patients with thyroid eye disease (TED).

Methods

This was a retrospective review of patients with active TED who underwent LSFG between October 2020 and June 2021. The mean blur rate (MBR) for different severities of active TED was analyzed by one-way analysis of variance (ANOVA).

Results

A total of 30 patients (60 eyes) with a diagnosis of active TED who underwent LSFG were included. The mean age was 49 (range, 33–74) years. Mean best-corrected visual acuity was the worst in the group with sight-threatening active TED (0.29 ± 0.33 logarithm of the minimum angle of resolution, p = 0.01). The MBR-overall was the highest in the group with mild active TED (28.5 ± 2.7), followed by that in the moderate to severe (23.6 ± 3.2), and in the sight-threatening (20.2 ± 4.3) active TED groups (p < 0.001). The MBR-vessel was 57.1, 47.0, and 39.3 in the mild, moderate to severe, and sight-threatening active TED groups, respectively (p < 0.001). The MBR-tissue was 16.9, 14.4, and 12.0 in the mild, moderate to severe, and sight-threatening active TED groups, respectively (p < 0.001).

Conclusions

This study demonstrates that optic nerve blood flow is lower with more severe active TED. In addition, LSFG is an effective, objective, and noninvasive method for evaluating the severity of TED.

The Unlikely Suspect: A Case Report of New-Onset Hyperthyroidism Due to Graves' Disease in an 89-Year-Old Gentleman and Review of Literature

Thyroid dysfunction in the elderly commonly manifests as hypothyroidism. With advancing age, toxic nodules are the more common cause of hyperthyroidism as compared to Graves' disease. Due to the lack of classical symptoms of hyperthyroidism in the elderly, the diagnosis can often be delayed. Previously, an 82-year-old gentleman with oropharyngeal dysphagia due to Graves' disease was the oldest reported case with atypical symptoms. We report a case of an 89-year-old gentleman with no prior history of thyroid disease, who presented with non-specific gastrointestinal symptoms that ultimately led to the diagnosis of hyperthyroidism secondary to Graves' disease. We also review the available literature regarding the pathophysiology, clinical presentation, and management of hyperthyroidism and Graves' disease in the elderly.

The impact of orbital bony or fat decompression on the outcome of strabismus surgery in patients with Graves' ophthalmopathy

BACKGROUND/PURPOSE

To compare the outcomes of strabismus surgery in patients with Graves' ophthalmopathy (GO) who had undergone bone removal orbital decompression (BROD) or fat removal orbital decompression (FROD) with those who had not undergone any orbital decompression.

METHODS

The records of patients with GO who underwent strabismus surgery over a period of 66 months were retrospectively reviewed.

RESULTS

Eighty-nine patients with a mean age of 55.1 ± 11.9 years were identified in this study. Twenty-two patients had prior BROD, 20 patients had prior FROD and 47 patients had no orbital decompression. Patients who had prior orbital decompression had an average of 1.6 strabismus surgeries per patient which was significantly higher compared to 1.2 strabismus surgeries in patients who had no orbital decompression (p = 0.02). The overall success rate of strabismus surgery was 68.2%, 80.0% and 80.9% following BROD, FROD and no orbital decompression respectively. The overall success rate of strabismus surgeries in patients with GO was 61% after the first surgery and 78% after the final surgery.

CONCLUSION

The management of strabismus in GO is complex and difficult. Prior orbital decompression is associated with more strabismus surgeries per patient with a trend towards a lower success rate for strabismus surgery. FROD is comparable to BROD with regards to its effects on the outcome of subsequent strabismus surgeries.

Association of orbital decompression and the characteristics of subsequent strabismus surgery in thyroid eye disease

OBJECTIVE

To examine the association of orbital decompression and the characteristics and outcome of subsequent strabismus surgery in patients with thyroid eye disease (TED).

METHODS

Data on patients with TED who underwent orbital decompression at the Goldschleger Eye Institute, Sheba Medical Center, Israel, between January 1990 to December 2011 were extracted. The characteristics of decompression and strabismus surgeries were recorded. The outcomes and association of both surgical procedures were analyzed. Statistical analysis included distribution, Pearson correlation, and matched paired tests.

RESULTS

145 eyes underwent orbital decompression, of which 45 eyes (31.0%) underwent strabismus surgery. Esotropia developed in 70% of the patients. Men and smokers underwent strabismus surgeries after decompression procedures more frequently than women and nonsmokers (χ² test, p = 0.07, 0.002). Moreover, patients who complained of diplopia before the decompression surgery underwent strabismus surgery more frequently (χ² test, p = 0.005). Seventy-seven percent of the patients who underwent medial wall decompression developed esotropia (χ² test, p = 0.004).

CONCLUSIONS

To the best of our knowledge, this is the largest series in the literature examining the association between decompression and strabismus surgeries. The patients' characteristics and the orbital walls involved in the decompression procedures are associated with the characteristics of subsequent strabismus that develops thereafter. These findings may have significant implications in planning TED management.

Approach to and treatment of thyroid disorders in the elderly

Thyroid gland dysfunction is prevalent in older adults and may be associated with significant morbidity if misdiagnosed and left untreated. Because of a decreased number of symptoms at presentation, an increased susceptibility to adverse events if not treated, and a greater likelihood of harm from treatment, the diagnosis and management of thyroid disorders in older adults can be challenging. This review focuses on the epidemiology, clinical presentation, risks and complications, and management of thyroid disorders in older adults, including hyperthyroidism, hypothyroidism, thyroid nodules, and thyroid cancer.

Toll-like receptor gene polymorphisms are associated with susceptibility to Graves' ophthalmopathy in Taiwan males

BACKGROUND

Toll-like receptors (TLRs) are a family of pattern-recognition receptors, which plays a role in eliciting innate/adaptive immune responses and developing chronic inflammation. The polymorphisms of TLRs have been associated with the risk of various autoimmune diseases, including systemic lupus erythematosus (SLE), multiple sclerosis and rheumatorid arthritis. The aim of this study was to evaluate whether TLR genes could be used as genetic markers for the development of Graves' ophthalmopathy (GO).

METHODS

6 TLR-4 and 2 TLR-9 gene polymorphisms in 471 GD patients (200 patients with GO and 271 patients without GO) from a Taiwan Chinese population were evaluated.

RESULTS

No statistically significant difference was observed in the genotypic and allelic frequencies of TLR-4 and TLR-9 gene polymorphisms between the GD patients with and without GO. However, sex-stratified analyses showed that the association between TLR-9 gene polymorphism and GO phenotype was more pronounced in the male patients. The odds ratios (ORs) was 2.11 (95% confidence interval [CI] = 1.14-3.91) for rs187084 AàG polymorphism and 1.97 (95% CI = 1.07-3.62) for rs352140 AàG polymorphism among the male patients. Increasing one G allele of rs287084 and one A allele of rs352140 increased the risk of GO (p values for trend tests were 0.0195 and 0.0345, respectively). Further, in haplotype analyses, the male patients carrying the GA haplotype had a higher risk of GO (odds ratio [OR] = 2.02, 95% confidence interval [CI] = 1.09-3.73) than those not carrying the GA haplotype.

CONCLUSION

The present data suggest that TLR-9 gene polymorphisms were significantly associated with increased susceptibility of ophthalmopathy in male GD patients.

Older subjects with hyperthyroidism present with a paucity of symptoms and signs: a large cross-sectional study

CONTEXT

The absence of classical symptoms and signs of hyperthyroidism often results in delayed diagnosis and treatment.

OBJECTIVES

The objective of the study was to determine the prevalence of symptoms and signs of hyperthyroidism according to patients' age and gender as well as severity and type of hyperthyroidism.

DESIGN, PARTICIPANTS AND SETTING

This was a cross-sectional study of 3049 consecutive patients with hyperthyroidism presenting to a single secondary/tertiary care clinic.

MAIN OUTCOME MEASURES

Calculation of adjusted odds ratios for presence/absence of symptoms/signs of hyperthyroidism simultaneously analyzing the influence of patients' age/gender, disease etiology/severity, symptom duration, and smoking.

RESULTS

The majority of patients older than 61 yr had two or more symptoms. The lowest proportion of subjects reporting five or more symptoms was found in those older than 61 yr. Increasing age was associated with reduced adjusted odds ratio for the presence of most classical symptoms except for weight loss and shortness of breath, independent of disease severity. Those with more severe hyperthyroidism and smokers had increased odds ratios for most symptoms. Older age, higher serum free T(4) concentrations at diagnosis, male gender, and toxic nodular hyperthyroidism were independently associated with risk of atrial fibrillation. Signs of ophthalmopathy were associated with increasing age, smoking, longer symptom duration, and female gender.

CONCLUSIONS

Classical symptoms and signs of hyperthyroidism are significantly less prevalent in older patients and more prevalent in smokers and subjects with higher free T(4) concentrations. We propose a lower threshold for performing thyroid function tests in patients older than 60 yr, especially in those presenting with atrial fibrillation, weight loss, or shortness of breath.

Association studies of interleukin-8 gene in Graves' disease and Graves' ophthalmopathy

Graves' disease (GD) is an autoimmune disorder, and the most common extrathyroidal manifestation is Graves' ophthalmopathy (GO), which is believed to be caused by a complex interaction between genetic and environmental factors. Many studies have reported that interleukin-8 (IL-8), a potent pro-inflammatory cytokine, is associated with many autoimmune diseases and could increase the degree of lymphocyte infiltration within the thyroid gland. The aim of the present study is to elucidate whether IL-8 is associated with the development of GD and GO. The serum concentration of IL-8 was tested in 39 primary GD patients, 43 treated active GO patients, and 24 healthy controls. We also performed an association study with the IL-8 gene polymorphism rs2227306 between 642 patients and 648 healthy controls in Chinese population. Our data showed that the expression level of IL-8 was associated with the development of GD, and the C-allele frequency of SNP rs2227306 was significantly higher in GD and GO patients compared with healthy controls. These results suggest that IL-8 is strongly associated with GD and GD.