Management of Graves' ophthalmopathy

Vascular changes of the peripapillary choroidal area in the thyroid orbitopathy

PURPOSE

The aim of this study was to investigate the peripapillary choroidal vascular changes in thyroid orbitopathy (TO).

METHODS

The study included 20 eyes of 10 patients with active TO (aTO), 30 eyes of 15 patients with inactive TO (inaTO) and 30 eyes of 30 healthy subjects. The peripapillary choroidal vascular change was assessed with peripapillary choroidal vascular index (pCVI), peripapillary choroidal luminal area (pLA), peripapillary choroidal stromal area (pSA), peripapillary total choroidal area (pTCA).

RESULTS

Compared to the control group, there was a reduction in the nasal and temporal areas of pCVI in both the aTO and inaTO groups (aTO vs control: nasal p = 0.001 and temporal p = 0.004; inaTO vs control: nasal p = 0.007 and temporal p < 0.001), while the inferior area was lower only in the inaTO group (p = 0.001). Compared to the other groups, the inaTO group exhibited a decrease pSA (vs aTO: total p = 0.004, inferior p = 0.02 and vs control: total p = 0.01, inferior p = 0.03), pLA (vs aTO: total p = 0.02, inferior p = 0.02, temporal p < 0.001 and vs control: total p = 0.002, inferior p < 0.001, temporal p < 0.001) and pTCA (vs aTO: total p = 0.009, inferior p = 0.01, temporal p < 0.001 and vs control: total p = 0.003, inferior p = 0.001, temporal p < 0.001).

CONCLUSION

The horizontal area (nasal and temporal area) of the peripapillary choroidal vascular structure may be more sensitive than the vertical area in TO patients. The first affected quadrant of RPC-VD in the active TO may be the inferior quadrant. Structural or vascular choroidal changes may occur during the chronic or post-active phase of the disease.

Surgical management of dysthyroid optic neuropathy: A systematic review

OBJECTIVE

There is currently no recommendation on the optimal surgical management for dysthyroid optic neuropathy (DON). The aim of this study is to systematically review the surgical management of DON and its outcome on visual acuity (VA).

DATA SOURCES

MEDLINE, Cochrane Library, and clinicaltrials.gov REVIEW METHODS: A systematic review of studies about the surgical management of DON was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Articles were included if preoperative and postoperative VA in logMAR (Logarithm of the Minimum Angle of Resolution) were available.

RESULTS

Fifteen articles were included in the study accounting for 669 orbits. The mean VA improvement was of 0.44 logMAR overall, 0.41 logMAR for 1-wall, 0.41 logMAR for 2-wall, and 0.55 logMAR for 3-wall decompressions. The mean reduction in exophthalmos was 4.9 mm overall, 4.3 mm for 1-wall, 4.54 mm for 2-wall, and 6.02 for 3-wall decompressions. The mean new onset diplopia (NOD) rate was 19.84% overall, 19,12% for 1-wall, 20.75% for 2-wall, and 19.83% for 3-wall decompressions.

CONCLUSION

The results are limited due to the high number of biases in the included studies. It seems that 3-wall decompression offers the best VA improvement and proptosis reduction although also the highest NOD and complications rate. Two-wall balanced decompression or 1-wall inferomedial decompression seems to be effective with less morbidity.

Monoclonal antibodies in neuro-ophthalmology

Neuro-ophthalmologic diseases include a broad range of disorders affecting the afferent and efferent visual pathways. Recently, monoclonal antibody (mAb) therapies have emerged as a promising targeted approach in the management of several of these complex conditions. Here, we describe the mechanism-specific applications and advancements in neuro-ophthalmologic mAb therapies. The application of mAbs in neuro-ophthalmologic diseases highlights our increasing understanding of disease-specific mechanisms in autoimmune conditions such as neuromyelitis optica, thyroid eye disease, and myasthenia gravis. Due to the specificity of mAb therapies, applications in neuro-ophthalmologic diseases have yielded exceptional clinical outcomes, including both reduced rate of relapse and progression to disability, visual function preservation, and quality of life improvement. These advancements have not only expanded the range of treatable neuro-ophthalmologic diseases but also reduced adverse events and increased the response rate to treatment. Further research into neuro-ophthalmologic disease mechanisms will provide accurate and specific targeting of important disease mediators through applications of future mAbs. As our understanding of these diseases and the relevant therapeutic targets evolve, we will continue to build on our understanding of how mAbs interfere with disease pathogenesis, and how these changes improve clinical outcomes and quality of life for patients.

Application of artificial intelligence in the assessment of thyroid eye disease (TED) - a scoping review

Background

There is emerging evidence which suggests the utility of artificial intelligence (AI) in the diagnostic assessment and pre-treatment evaluation of thyroid eye disease (TED). This scoping review aims to (1) identify the extent of the available evidence (2) provide an in-depth analysis of AI research methodology of the studies included in the review (3) Identify knowledge gaps pertaining to research in this area.

Methods

This review was performed according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA). We quantify the diagnostic accuracy of AI models in the field of TED assessment and appraise the quality of these studies using the modified QUADAS-2 tool.

Results

A total of 13 studies were included in this review. The most common AI models used in these studies are convolutional neural networks (CNN). The majority of the studies compared algorithm performance against healthcare professionals. The overall risk of bias and applicability using the modified Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool led to most of the studies being classified as low risk, although higher deficiency was noted in the risk of bias in flow and timing.

Conclusions

While the results of the review showed high diagnostic accuracy of the AI models in identifying features of TED relevant to disease assessment, deficiencies in study design causing study bias and compromising study applicability were noted. Moving forward, limitations and challenges inherent to machine learning should be addressed with improved standardized guidance around study design, reporting, and legislative framework.

Dysthyroid Optic Neuropathy

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.

Machine learning-assisted system using digital facial images to predict the clinical activity score in thyroid-associated orbitopathy

Although the clinical activity score (CAS) is a validated scoring system for identifying disease activity of thyroid-associated orbitopathy (TAO), it may produce differing results depending on the evaluator, and an experienced ophthalmologist is required for accurate evaluation. In this study, we developed a machine learning (ML)-assisted system to mimic an expert's CAS assessment using digital facial images and evaluated its accuracy for predicting the CAS and diagnosing active TAO (CAS ≥ 3). An ML-assisted system was designed to assess five CAS components related to inflammatory signs (redness of the eyelids, redness of the conjunctiva, swelling of the eyelids, inflammation of the caruncle and/or plica, and conjunctival edema) in patients' facial images and to predict the CAS by considering two components of subjective symptoms (spontaneous retrobulbar pain and pain on gaze). To train and test the system, 3,060 cropped images from 1020 digital facial images of TAO patients were used. The reference CAS for each image was scored by three ophthalmologists, each with > 15 years of clinical experience. We repeated the experiments for 30 randomly split training and test sets at a ratio of 8:2. The sensitivity and specificity of the ML-assisted system for diagnosing active TAO were 72.7% and 83.2% in the test set constructed from the entire dataset. For the test set constructed from the dataset with consistent results for the three ophthalmologists, the sensitivity and specificity for diagnosing active TAO were 88.1% and 86.9%. In the test sets from the entire dataset and from the dataset with consistent results, 40.0% and 49.9% of the predicted CAS values were the same as the reference CAS, respectively. The system predicted the CAS within 1 point of the reference CAS in 84.6% and 89.0% of cases when tested using the entire dataset and in the dataset with consistent results, respectively. An ML-assisted system estimated the clinical activity of TAO and detect inflammatory active TAO with reasonable accuracy. The accuracy could be improved further by obtaining more data. This ML-assisted system can help evaluate the disease activity consistently as well as accurately and enable the early diagnosis and timely treatment of active TAO.

Old Bottle, New Wine: Diplopia Sans Proptosis as the Sole Presentation of Thyroid Orbitopathy

Thyroid orbitopathy holds a dominant place in the list of causes for external ophthalmoplegia and is commonly accompanied by eye surface signs such as congestion, lacrimation, and proptosis. An elderly male presented to us with painless diplopia in the absence of proptosis, conjunctival congestion, tearing or irritative symptoms. He had bilateral complete external ophthalmoplegia. He was evaluated to have hypothyroidism with elevated anti-thyroid peroxidase antibodies. MRI revealed bulky extraocular muscles in a pattern of sparing of tendinous insertions, highly suggestive of thyroid orbitopathy. He was managed with IV steroid pulse and thyroxine supplementation with minimal improvement. Through this case report, we highlight an unusual presentation of thyroid eye disease in the form of isolated diplopia, in the absence of other usual eye signs. We also emphasize the characteristic typical neuroimaging signs, such as the 'Coca Cola bottle' sign, which strongly augments the diagnosis in an atypical setting.

Effectiveness of orbital decompression for endocrine orbitopathy and impact on quality of life: A retrospective study

To evaluate the effectiveness of orbital decompression intervention in terms of variation of the exophthalmos and to highlight its association with changes in quality of life before and after surgery. Medical records of patients with moderate-severe GO who underwent orbital decompression surgery were retrospectively reviewed. Clinical parameters, including demographic characteristics, surgical technique, exophthalmos values, and QoL using the GO-QoL questionnaire were studied before and after orbital decompression and analyzed. Thirty patients were included in the study. Surgery was bilateral 26 patients and unilateral in 4 patients (56 operated orbits). Before surgery the average value of exophthalmometry was 24.96 (±2.68) mm. The questionnaires submitted for assessment of the quality of life (GO-QoL) yielded average values of 43.3 for the visual function (VF) and 44.03 for the appearance (AP). 20 patients (64.3%) underwent combined bone and fat decompression surgery, 9 underwent fat decompression, and 1 underwent bone decompression. After surgery, the average values of exophthalmometry were 21.8 (±2.34) mm, with an average reduction of 3.20 (±2.35) mm. (p < 0.0001) GO-QoL questionnaires administered after surgery showed a mean VF score of 76.73 (±26.75), and AP score of 73.71 (±21.89). (p < 0.001, paired t-test) Orbital decompressive surgery is not only effective on GO, but also on a long-term improvement in overall well-being, self-confidence and QoL.

Current Knowledge on Graves' Orbitopathy

(1) Background: Graves' orbitopathy (GO) is an autoimmune inflammation of the orbital tissues and the most common extra-thyroid symptom of Graves' disease (GD). Mild cases of GO are often misdiagnosed, which prolongs the diagnostic and therapeutic process, leading to exacerbation of the disease. A severe course of GO may cause permanent vision loss. (2) Methods: The article presents an analysis of GO-its etiopathogenesis, diagnostics, current treatment and potential future therapeutic options based on a review of the currently available literature of the subject. (3) Results: Current treatment of the active GO consists predominantly in intravenous glucocorticoids (GCs) administration in combination with orbital radiotherapy. The growing knowledge on the pathogenesis of the disease has contributed to multiple trials of the use of immunosuppressive drugs and monoclonal antibodies which may be potentially effective in the treatment of GO. Immunosuppressive treatment is not effective in patients in whom a chronic inflammatory process has caused fibrous changes in the orbits. In such cases surgical treatment is performed-including orbital decompression, adipose tissue removal, oculomotor muscle surgery, eyelid alignment and blepharoplasty. (4) Conclusions: Management of GO is difficult and requires interdisciplinary cooperation in endocrinology; ophthalmology, radiation oncology and surgery. The possibilities of undertaking a reliable assessment and comparison of the efficacy and safety of the therapeutic strategies are limited due to the heterogeneity of the available studies conducted mostly on small group of patients, with no comparison with classic systemic steroid therapy. The registration by FDA of Teprotumumab, an IGF1-R antagonist, in January 2020 may be a milestone in future management of active GO. However, many clinical questions require to be investigated first.

Preliminary study of abnormalities in saccade dynamics in patients with hyperthyroidism with no pre-existing eye damage

The present study investigated the relationship between hyperthyroidism and thyroid-associated ophthalmopathy by examining saccade dynamics to identify defects in eye tracking in patients with hyperthyroidism with no pre-existing eye damage and sensitive indicators that discriminated eye tracking ability in hyperthyroidism. A total of 33 outpatients with hyperthyroidism and 26 healthy controls participated in visually guided saccade (VGS) analysis. Patients with hyperthyroidism were divided into groups based on their medication status (medicated vs. unmedicated). Main sequence analysis was performed to identify differences in peak velocity and duration, and a general linear model (GLM) was used to identify differences in latency, peak acceleration and peak deceleration among the groups. The present study compared differences in the Spearman's correlation coefficient of the duration of saccades and the acceleration asymmetric index (R_AD) among the groups. V_max values (V_max was the asymptotic value of the PV of saccades of large amplitude) were significantly different between the healthy control and unmedicated-hyperthyroidism groups. The results of the GLM-based analysis indicated no significant differences in saccade latency among the three groups. Peak acceleration was significantly different between the healthy control and unmedicated-hyperthyroidism groups (P<0.01). Peak deceleration was significantly different between the healthy control, unmedicated- and medicated-hyperthyroidism groups (P<0.01). R_AD was significantly different between the healthy control and medicated-hyperthyroidism groups (P=0.004). The results of the present study suggested that patients with hyperthyroidism with no pre-existing eye damage exhibited significantly altered saccade dynamics during VGS. Therefore, R_AD may be used as an indicator to monitor the level of eye movement coordination.

Establishment of a tear protein biomarker panel differentiating between Graves' disease with or without orbitopathy

Background

Graves’ orbitopathy (GO) is an autoimmune inflammatory ocular complication and one of the most frequent manifestations of Graves’ disease (GD). Clinical judgment of GO is subjective sometimes leading to clinical and therapeutic challenges. Better tools to diagnose this severe complication are warranted.

Patients and methods

The aim of the present study was to evaluate tear levels of LYZ, LACRT and AZGP1 in GD patients with or without GO, as possible biomarkers for GO. Tear samples were collected from GD patients with moderate-to-severe GO (n = 21) and no clinical signs of GO (n = 21). Additionally, 18 GD patients with mild GO and 9 patients without GO were included in a further part of the study.

Results

Tear levels of LYZ (p < 0.001), LACRT (p = 0.004) and AZGP1 (p = 0.001) were significantly elevated in GD patients with moderate-to-severe GO compared to GD patients without GO. The discriminatory power of the three biomarkers, combined in a panel was confirmed by ROC plot analysis, with an AUC value of 0.93 (sensitivity of 95%; specificity of 80%). Since LYZ showed the best performance in discriminating between GD patients with (moderate-to-severe) and without GO (in combination with limited sample volume available), LYZ levels were also measured in tears from GD patients with mild GO and without GO. Significantly higher levels of LYZ were measured in GD patients with mild GO compared to those without GO (p = 0.003).

Conclusions

We have established a novel three-protein biomarker panel that is able to discriminate between GD patients with and without GO, which might aid in diagnostic evaluation of GO as well as an indicator for disease activity.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT COMMENTARY

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

Acute liver damage following intravenous glucocorticoid treatment for Graves' ophthalmopathy

PURPOSE

Over the last years, there have been several reports on the occurrence of acute liver damage (ALD) in patients affected with Graves' ophthalmopathy (GO) receiving intravenous glucocorticoids (ivGCs). This article is aimed at reviewing the literature on this specific topic and reporting two new cases of ALD occurring in GO patients while on ivGCs.

METHODS

The terms "glucocorticoid therapy" and "Graves' Ophthalmopathy"/"Graves' Orbitopathy"/"Thyroid eye disease" were used both separately and in conjunction with the terms "liver disease," "liver damage," "hepatotoxicity," "liver failure," to search MEDLINE for articles published since the first report of ALD in 2000 and up to 2015.

RESULTS

ALD [defined as an increase in alanine aminotransferase (ALT) >300 U/L] during or after completion of ivGCs has been so far reported in 17 fully documented cases. Overall, one-half of those patients were diagnosed as having autoimmune hepatitis (AIH) and in the vast majority of the remaining cases a diagnosis of methylprednisolone(MP)-induced hepatotoxicity was suspected. The clinical course of liver injury varied from asymptomatic hypertransaminasemia in the vast majority of patients to fatal hepatic failure in four patients receiving higher (>8 g) cumulative doses of MP.

CONCLUSIONS

The overall risk of ALD is relatively low (~1 %), and seems higher using a single dose >0.5 g and a cumulative dose >8.5 g MP. Whenever ivGC treatment is required, serum liver enzymes, viral hepatitis markers, and autoantibodies related to AIH should be obtained prior to ivGC administration. Liver function should be monitored during ivGC and up to 6 months after the end of treatment. Prolonging observation after 6 months is likely unnecessary, since all cases of ALD so far reported always occurred well within this term.

Evaluation of quality of life in patients with Graves´ ophthalmopathy, before and after orbital decompression

Graves' ophthalmopathy (GO) is a potentially sight threatening orbital disease that can have a large negative impact on the quality of life of the patient. Studies on long-term effects of GO on the quality of life are few. The aim of this study is to evaluate the health-related quality of life in patients with GO, before and after orbital decompression surgery. This is a prospective, longitudinal, interventional study in which patients who had orbital decompression were given the Graves´ ophthalmopathy quality of life questionnaire (GO-QOL) before and after surgery. The GO-QOL is a disease specific instrument to measure health-related quality of life. The answers are transformed into scores from 0-100 on 2 subscales. Higher score indicates better health. An additional patient satisfaction questionnaire was also given post-surgery. A significant, long-term, improvement in quality of life after orbital decompression was noted (p < 0.001, paired t-test). 50 patients were included and follow-up time was 5.3 ± 1.2 years (mean ± SD). The QOL-scores increased 28 ± 35 and 26 ± 31 points, respectively, on the two subscales, "visual functioning" and "appearance" (mean ± SD). The patient satisfaction questionnaire showed that 88% of the patients would recommend orbital decompression to a fellow patient. Persistent disturbing oscillopsia was seen in 2% and persistent disturbing infraorbital nerve hypoesthesia in 8% of the patients. Orbital decompression surgery has a positive effect on quality of life for patients with severe GO. The GO-QOL questionnaire showed significant improvement in QOL-scores even many years after surgery.

Current Insights into the Pathogenesis of Graves' Ophthalmopathy

Environmental, genetic, and immune factors are at play in the development of the variable clinical manifestations of Graves' ophthalmopathy (GO). Among the environmental contributions, smoking is the risk factor most consistently linked to the development or worsening of the disease. The close temporal relationship between the diagnoses of Graves' hyperthyroidism and GO have long suggested that these 2 autoimmune conditions may share pathophysiologic features. The finding that the thyrotropin receptor (TSHR) is expressed in orbital fibroblasts, the target cells in GO, supported the notion of a common autoantigen. Both cellular and humeral immunity directed against TSHR expressed on orbital fibroblasts likely initiate the disease process. Activation of helper T cells recognizing TSHR peptides and ligation of TSHR by TRAb lead to the secretion of inflammatory cytokines and chemokines, and enhanced hyaluronic acid (HA) production and adipogenesis. The resulting connective tissue remodeling results in varying degrees extraocular muscle enlargement and orbital fat expansion. A subset of orbital fibroblasts express CD34, are bone-marrow derived, and circulate as fibrocytes that infiltrate connective tissues at sites of injury or inflammation. As these express high levels of TSHR and are capable of producing copious cytokines and chemokines, they may represent an orbital fibroblast population that plays a central role in GO development. In addition to TSHR, orbital fibroblasts from patients with GO express high levels of IGF-1R. Recent studies suggest that these receptors engage in cross-talk induced by TSHR ligation to synergistically enhance TSHR signaling, HA production, and the secretion of inflammatory mediators.

Age and Dose Are Major Risk Factors for Liver Damage Associated with Intravenous Glucocorticoid Pulse Therapy for Graves' Orbitopathy

BACKGROUND

High-dose intravenous glucocorticoid (ivGC) pulse therapy, which is commonly used for Graves' orbitopathy (GO), has been associated with acute liver damage (ALD), resulting in a fatal outcome in a few cases. No certain risk factors for ALD have been established. Consequently, a large retrospective cohort study was performed.

METHODS

The relationship between ALD and several potential risk factors was assessed in 1076 consecutive patients with GO given ivGC. ALD was defined as an increase of alanine aminotransferase ≥300 IU/L.

RESULTS

Fourteen cases of ALD were recorded, resulting in a morbidity of 1.3%. Thirteen patients recovered and one died, resulting in a mortality of 0.09%. There was a significant, positive correlation of ALD with age and methylprednisolone acetate (MPA) cumulative dose, and ALD was more common (relative risk [RR]=2.8; p=0.05) in patients aged ≥53 years (9/420; 2.14%) than in those aged <53 years (5/656; 0.76%). In patients aged ≥53 years, there was a significant positive correlation of ALD with MPA cumulative dose, and with MPA dose per infusion. Thus, the frequency of ALD in this age group was greater (RR=3.48; p=0.04) in patients with a MPA dose per infusion ≥0.7 g (5/111, 4.5% vs. 4/308, 1.29%). Regardless of age, no cases of ALD were observed for MPA doses per infusion <0.57 g.

CONCLUSIONS

Age and MPA dose are significant risk factors for ALD, with the following practical implications. First, the total MPA cumulative dose should not exceed 8.5 g (the average dose in patients without ALD). Second, in patients aged ≥53 years, selection and observation should be quite strict. However, being aged ≥53 years should not be seen as an absolute contraindication to ivGC, especially in patients with severe GO, considering that the risk of ALD, although statistically significant, was relatively low. Third, the MPA dose should not exceed 0.57 g per infusion, a measure to be applied regardless of age.

Effect of double-fold surgery on spontaneous resolution of Graves' upper eyelid retraction

OBJECTIVE

To investigate the effect of previous incisional double-fold surgery on spontaneous resolution of eyelid retraction caused by Graves orbitopathy (GO) in Asian individuals.

DESIGN

Retrospective review of medical records.

PARTICIPANTS

Patients (N = 30; 39 eyes) with eyelid retraction associated with GO with symptom duration of less than 6 months.

METHODS

Patients who visited the Ophthalmology Department of Severance Hospital, Yonsei University, between January 2010 and December 2011, followed up for more than 6 months and in a euthyroid state with antithyroid drug treatment were included. Patients treated with steroids or who underwent surgery during follow-up were excluded. Upper scleral show was measured as the distance between the central upper lid margin and limbus at initial presentation and after 6 months. Comparative analysis was performed between the 2 groups delineated by history (n = 12; 16 eyes), or lack thereof (n = 18; 23 eyes), of incisional double-fold surgery before onset of GO symptoms and signs.

RESULTS

Patient demographics and initial upper scleral show were not significantly different between groups. In both groups, upper scleral show significantly decreased at 6 months of follow-up (p < 0.001 in both groups); however, improvement of upper scleral show was significantly reduced in patients who had undergone previous double-fold surgery (0.8 ± 0.5 mm) than in nonsurgical patients (1.8 ± 0.5 mm; p < 0.001).

CONCLUSIONS

Graves eyelid retraction resolves spontaneously over time, albeit not completely. Previous double-fold surgery hinders the degree of spontaneous resolution, probably because of the fibrosis and cicatrization between the skin, the subcutaneous layer, and the levator complex.

The influence of prior hyperthyroidism on euthyroid graves' ophthalmopathy

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

The course of retinal vasculitis

AIMS

To determine if characteristics of retinal vasculitis correlate with ocular complications, or the response to different lines of treatment.

MATERIALS AND METHODS

We performed a computerised database analysis of 56 patients evaluated for uveitis at the Casey Eye Institute from September 1985 until May 2010. All patients had non-infectious retinal vasculitis and at least 1 year of follow-up.

RESULTS

Although occlusive vasculitis was rare, retinal neovascularisation occurred much more commonly in the occlusive vasculitis subgroup than among the non-occlusive vasculitis subgroup (p<0.01). Epiretinal membrane (ERM) was found more commonly in the retinal vasculitis patients who presented with cotton wool spots and intraretinal haemorrhage compared to retinal vasculitis patients who presented with sheathing noted on clinical examination (p<0.01). Smoking was significantly related to vision loss. Age at presentation below 40 years correlated with therapy beyond oral corticosteroids

CONCLUSIONS

The heterogeneity of retinal vasculitis should be considered in providing prognostic information. Neovascularisation occurs more commonly in occlusive retinal vasculitis, and ERM is diagnosed more frequently in conjunction with cotton wool spots and intraretinal haemorrhage rather than just vascular sheathing. Cigarette use predicts visual loss and patients who are relatively young often receive treatment beyond oral corticosteroids.

Total Thyroidectomy as Primary Definitive Treatment for Graves’ Hyperthyroidism

The objective of this study was to compare the results of total thyroidectomy (TT) for hyperthy-roidism secondary to Graves’ disease (GD) with TT for other benign thyroid diseases to determine if TT should be considered more often as first-line therapy for GD. Seven hundred eighty patients underwent TT for benign disease: 203 for GD, 56 for other hyperthyroidisms, and 521 for other benign diseases from March 1, 2003, to December 31, 2009. The perioperative results of these three groups were compared for demographics, blood loss, operative time, complications, and hospitalization. There were no significant differences among the three groups except the patients with GD were more likely to be younger (42 vs 56 vs 57 years; P < 0.001), have more blood loss (154 vs 99 vs 110 mL; P = 0.05), and were more likely to develop permanent hypoparathyroidism (1.0 vs 1.8 vs 0%; P = 0.03) when compared with other causes of hyperthyroidism and other benign thyroid diseases. Permanent recurrent laryngeal nerve injury did not occur in the GD group (0 vs 0 vs 0.4% nerves at risk; P = 0.69) with transient recurrent laryngeal nerve injury occurring in 1.7 versus 2.7 versus 3.1 per cent nerves at risk ( P = 0.35). The lack of a euthyroid state preoperatively had no influence on surgical outcomes or complications. Eighty percent of the TTs for GD were done as same-day outpatient procedures. TT offers a safe, low-risk, and rapid cure for GD to justifiably be considered as a reasonable first-line therapy in selected patients with Graves’ hyperthyroidism.

Update on advanced imaging options for thyroid-associated orbitopathy

Thyroid-associated orbitopathy (TAO) is a diverse spectrum of signs and symptoms that appears to have immunologic and pathologic causative factors as diverse as its clinical presentations. Lymphocytes, hormones, and cytokines affect orbital fibroblasts and other similar cells, which exert their effects on orbital tissues, including the extraocular muscles, orbital fat, and optic nerve. This complicated inflammatory cascade and the myriad of clinical findings that result contributes to the active phase of TAO. The distinction between the active and inactive phases of TAO is an important one, as the proper treatment will depend on the disease phase and degree thereof. Several clinical grading scales and scores have been established to help qualify and quantify the disease severity. Aiding clinical exam and acumen, proper and reproducible imaging of the orbit and ocular adnexa is incredibly important to the management of TAO. Orbital ultrasound, computed tomography, magnetic resonance imaging, and scintigraphy each have unique abilities, including quantifying orbital changes, assessing disease activity, correlating orbital findings with clinical changes, guiding appropriate treatment, and monitoring therapeutic responses. Further, study ease, accessibility, cost, sensitivity, specificity, reproducibility, and risks are all important considerations in picking the right test with which to diagnose and follow TAO. This analysis will provide a review of orbital imaging for TAO, including the mechanism of each imaging technique as well as their rationales, advantages, disadvantages, and utilities.

Management of patients in a combined thyroid eye clinic in secondary care

The European Group on Graves' Orbitopathy (EUGOGO) recommends the use of specialised multidisciplinary clinics for the management of thyroid eye disease (TED). In the UK, many patients with TED are managed outside of specialised clinics. We describe the organisation of a combined TED clinic in a secondary care setting and present the result of a prospective audit of the patient characteristics and outcomes during the first four years of a combined TED clinic. Of a total of 132 patients referred to the TED clinic, 114 (86 %) had TED (90 females, median age 56 years; range 17-90 years). At presentation, 77 (67 %) were current or ex-smokers and 99 (87 %) were biochemically euthyroid. Median duration of eye symptoms was 12 months. Fifty-two percent, 45 and 3 had mild, moderate-to-severe and sight-threatening TED, respectively. Only 18 % of patients had a clinical activity score (CAS) of ≥3. Sixty-nine patients (61 %) required follow-up appointments in the TED clinic. In those who required follow-up, 43 % (n = 30) received either immunosuppressive or surgical treatment. CAS improved from first to final visit, with 29 % (n = 20) having a CAS of ≥3 at the first visit and 1 % (n = 1) at the final visit (p = 0.0001). There was also a decrease in prevalence of smoking and thyroid dysfunction at the final visit. A multidisciplinary specialised TED clinic offers an optimal setting for managing patients with TED; however, patients are often referred late to a specialist TED clinic.

IgG4-related ocular adnexal disease mimicking thyroid-associated orbitopathy

A 72-year-old man presented with bilateral eyelid swelling and redness. An orbital CT scan showed bilateral proptosis, extraocular muscle enlargement and swollen lacrimal glands, mimicking thyroid-associated orbitopathy (TAO) with Hashimoto's thyroiditis (HT). During the patient's clinical course, spontaneous remission of lung consolidation (35 × 26 mm) was seen. A diagnosis of IgG4-related disease (IgG4-RD) was made based on an elevated serum IgG4 level (1,020 mg/dL; normal, 4-108), predominance of IgG4-positive plasma cells (IgG4/IgG: 35/70 in HPF) in the lacrimal glands and typical features of Mikulicz's disease. This report provides a novel description of this unusual disease entity among HT, TAO and IgG4-RD.

Thyroid volume and severity of Graves' orbitopathy

BACKGROUND

Graves' orbitopathy (GO) is thought to be related to one or more autoantigens present in the thyroid and in orbital tissues. Although this may not imply a quantitative relation between thyroid antigens and degree of GO, which in turn is a risk factor for a more pronounced GO, we postulated that the severity of GO may parallel the amount of thyroid tissue, namely, the size of the thyroid gland. This hypothesis is also based on the observation that patients with Graves' disease presenting with large goiters tend to have more severe hyperthyroidism. Thus, we evaluated retrospectively whether there is a correlation between the degree of GO at its first observation and, among other parameters, the thyroid volume.

METHODS

Eighty-six consecutive patients with untreated GO lasting for no longer than 24 months underwent an endocrinological and an ophthalmological evaluation, the latter including: exophthalmometry, eyelid width, clinical activity score (CAS), diplopia, and visual acuity. The overall degree of GO was ranked using the NOSPECS score as well as a modification of the NOSPECS score. The following parameters were considered for correlations: time since GO appearance, time since detection of hyperthyroidism, FT3, anti-thyrotropin receptor antibodies, thyroid volume, and cigarette-years.

RESULTS

Thyroid volume, but not the other parameters, correlated significantly by simple regression with exophthalmometry (p=0.02) and CAS (p=0.02). The standard NOSPECS score correlated with FT3 (p=0.05), thyroid volume (p=0.02), and cigarette-years (p=0.03), by simple, but not by multiple regression analysis. The modified NOSPECS score correlated with thyroid volume (p=0.007) and cigarette-years (p=0.04) by simple regression, and with thyroid volume also by multiple regression analysis (p=0.05).

CONCLUSIONS

Thyroid volume correlates with the severity of GO at its first observation, especially with exophthalmometry and CAS. The finding is in line with a possible pathogenetic role of antigens shared by the thyroid and orbital tissues. Nevertheless, other mechanisms may explain this observation, including an overall more reactive immune system in patients with a large goiter, resulting in more severe thyroid and eye disease, regardless of the nature of the autoantigen, or whether it is shared by the thyroid and the orbit.

Enalapril reduces proliferation and hyaluronic acid release in orbital fibroblasts

BACKGROUND

Orbital fibroblast proliferation and hyaluronic acid (HA) release are responsible for some of the clinical features of Graves' ophthalmopathy (GO). Thus, inhibition of these processes may be a possible therapeutic approach to this syndrome. Enalapril, a widely used antihypertensive drug, was found to have some inhibitory actions on fibroblast proliferation in cheloid scars in vivo, based on which we investigated its effects in primary cultures of orbital fibroblasts from GO patients and control subjects.

METHODS

Primary cultures of GO and control fibroblasts were treated with enalapril or with a control compound (lisinopril). Cell proliferation assays, lactate dehydrogenase release assays (as a measure of cell necrosis), apoptosis assays, and measurement of HA in the cell media were performed.

RESULTS

Enalapril significantly reduced cell proliferation in both GO and control fibroblasts. Because enalapril did not affect cell necrosis and apoptosis, we concluded that its effects on proliferation reflected an inhibition of cell growth and/or a delay in cell cycle. Enalapril significantly reduced HA concentrations in the media from both GO and control fibroblasts.

CONCLUSIONS

Enalapril has antiproliferative and HA suppressing actions in both GO and control fibroblasts. Clinical studies are needed to investigate whether enalapril has any effects in vivo in patients with GO.

Radioiodine therapy in benign thyroid diseases: effects, side effects, and factors affecting therapeutic outcome

Radioiodine ((131)I) therapy of benign thyroid diseases was introduced 70 yr ago, and the patients treated since then are probably numbered in the millions. Fifty to 90% of hyperthyroid patients are cured within 1 yr after (131)I therapy. With longer follow-up, permanent hypothyroidism seems inevitable in Graves' disease, whereas this risk is much lower when treating toxic nodular goiter. The side effect causing most concern is the potential induction of ophthalmopathy in predisposed individuals. The response to (131)I therapy is to some extent related to the radiation dose. However, calculation of an exact thyroid dose is error-prone due to imprecise measurement of the (131)I biokinetics, and the importance of internal dosimetric factors, such as the thyroid follicle size, is probably underestimated. Besides these obstacles, several potential confounders interfere with the efficacy of (131)I therapy, and they may even interact mutually and counteract each other. Numerous studies have evaluated the effect of (131)I therapy, but results have been conflicting due to differences in design, sample size, patient selection, and dose calculation. It seems clear that no single factor reliably predicts the outcome from (131)I therapy. The individual radiosensitivity, still poorly defined and impossible to quantify, may be a major determinant of the outcome from (131)I therapy. Above all, the impact of (131)I therapy relies on the iodine-concentrating ability of the thyroid gland. The thyroid (131)I uptake (or retention) can be stimulated in several ways, including dietary iodine restriction and use of lithium. In particular, recombinant human thyrotropin has gained interest because this compound significantly amplifies the effect of (131)I therapy in patients with nontoxic nodular goiter.

Mechanism of action of a nanomolar potent, allosteric antagonist of the thyroid-stimulating hormone receptor

BACKGROUND AND PURPOSE

Graves' disease (GD) is an autoimmune disease in which the thyroid is overactive, producing excessive amounts of thyroid hormones, caused by thyroid-stimulating hormone (TSH) receptor-stimulating immunoglobulins (TSIs). Many GD patients also suffer from thyroid eye disease (Graves' ophthalmopathy or GO), as TSIs also activate TSH receptors in orbital tissue. We recently developed low molecular weight (LMW) TSH receptor antagonists as a novel therapeutic strategy for the treatment of GD and GO. Here, we determined the molecular pharmacology of a prototypic, nanomolar potent LMW TSH receptor antagonist, Org 274179-0.

EXPERIMENTAL APPROACH

Using CHO cells heterogeneously expressing human TSH receptors and rat FRTL-5 cells endogenously expressing rat TSH receptors, we determined the potency and efficacy of Org 274179-0 at antagonizing TSH- and TSI-induced TSH receptor signalling and its cross-reactivity at related follicle-stimulating hormone and luteinizing hormone receptors. We analysed the allosteric mode of interaction of Org 274179-0 and determined whether it is an inverse agonist at five naturally occurring, constitutively active TSH receptor mutants.

KEY RESULTS

Nanomolar concentrations of Org 274179-0 completely inhibited TSH (and TSI)-mediated TSH receptor activation with little effect on the potency of TSH, in accordance with an allosteric mechanism of action. Conversely, increasing levels of TSH receptor stimulation only marginally reduced the antagonist potency of Org 274179-0. Org 274179-0 fully blocked the increased basal activity of all the constitutively active TSH receptor mutants tested with nanomolar potencies.

CONCLUSIONS AND IMPLICATIONS

Nanomolar potent TSH receptor antagonists like Org 274179-0 have therapeutic potential for the treatment of GD and GO.

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.

Ultrasonography compared to magnetic resonance imaging in thyroid-associated Graves' ophthalmopathy

OBJECTIVE

To compare ultrasonography (US) to magnetic resonance imaging (MRI) and the clinical activity score (CAS) in Graves' ophthalmopathy.

SUBJECTS AND METHODS

Nineteen patients underwent extraocular muscle thickness measurements by US and MRI, reflectivity by US and signal-intensity ratio by MRI. There were also twelve US control subjects.

RESULTS

US median thicknesses were greater than in controls. Correlation was found between US and MRI in the median thickness of the left eye rectus medial muscle as well as between signal-intensity ratio (SIR) and thickness by US. An inverse correlation was found between reflectivity and SIR in the inferior and lateral rectus. On associating the tests for detecting activity the best results were obtained with CAS plus MRI (sensitivity 75%), and US and MRI (positive predictive value 77% and specificity 80%).

CONCLUSION

CAS and US results showed poor correlation with MRI results suggesting that they cannot replace each other but when combined these methods can improve the evaluation of thyroid-associated ophthalmopathy.

Neuro-ophthalmology of orbital disease

In this chapter the presentation and management of common orbital diseases are discussed. An accurate clinical history and assessment are essential, with computed tomography being the imaging of choice. Magnetic resonance imaging provides detail of intrinsic optic nerve disease and orbital apical or intracranial pathology, and ultrasonography is valuable in assessing anterior orbital masses, in particular vascular lesions. Inflammatory lesions require a tissue biopsy before immunosuppression is instituted. Exceptions to this principle are scleritis, myositis, thyroid eye disease, and characteristic orbital apex syndrome, in which delay in immune suppression may jeopardize visual outcome. The term "orbital pseudotumor" is now obsolete. The management of active thyroid eye disease includes immunosuppression and low-dose orbital radiotherapy. Urgent orbital decompression is indicated in the presence of nonresponsive optic neuropathy, and inactive disease is managed by decompression for exophthalmos, and correction of muscle imbalance and lid retraction. Subacute lacrimal gland inflammation, unresponsive to a few weeks of nonsteroidal treatment, may be due to underlying carcinoma and a specialist opinion should be sought without delay. Pleomorphic adenoma, with typical features on imaging, should always be excised intact to avoid subsequent pervasive malignant disease.

Comparison of steroid pulse therapy and conventional oral steroid therapy as initial treatment for autoimmune pancreatitis

BACKGROUND

The efficacy of oral steroid therapy for autoimmune pancreatitis (AIP) is well known, and oral prednisolone treatment is most usually commenced at 30-40 mg/day, but there have been few reports about comparative studies of oral steroid therapy and steroid pulse therapy as the initial treatment for AIP. We studied the clinical course and image findings to estimate the utility of steroid pulse therapy for AIP, comparing it with oral steroid therapy.

METHODS

Laboratory and image findings were assessed retrospectively in 11 patients who received steroid pulse therapy, and the findings were compared to those in 10 patients who received conventional oral steroid therapy.

RESULTS

Change in pancreatic size showed no significant difference between the therapies after 2 weeks of treatment. Significant improvement of lower bile duct strictures after 2 weeks of treatment and that of immunoglobulin values within 6 months were shown with both therapies. However, steroid pulse therapy showed significant improvement of γ-guanosine triphosphate (GTP) in 2 weeks and of alanine aminotransferase (ALT) in 2 and 8 weeks, compared with oral steroid therapy. Moreover, there was one patient in whom the lower bile duct stricture was not improved by oral steroid therapy, but it did show improvement with steroid pulse therapy.

CONCLUSIONS

Initial steroid pulse therapy is a beneficial alternative to oral steroid therapy for the improvement of bile duct lesions. In future, the accumulation of a larger number of patients receiving steroid pulse therapy is needed, and prospective studies will be required.

Quality of life in thyroid eye disease: impact of quality of care

Thyroid eye disease (TED) is a chronic debilitating condition causing physical discomfort, facial disfigurement and impaired visual function. The physical consequences of TED could have a negative and lasting impact on patients' employment, hobbies and psychosocial function. In this review, we assess the evidence of the impact of TED on patients' quality of life (QOL) and also explore the effects of suboptimal quality of care on QOL of patients with this disease. It is hoped that recent initiatives, including the Amsterdam declaration, to raise the quality of care for patients with TED will help to improve their QOL.

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.

Risk factors associated with the severity of thyroid-associated orbitopathy in Korean patients

Purpose

The purpose of this study is to identify risk factors for severe thyroid-associated orbitopathy (TAO) and compressive optic neuropathy in Korean patients.

Methods

This study was a retrospective comparative case series. All TAO patients who were first seen at our institution between 2005 and 2009 and who had follow-up periods of at least 6 months were included. Patients were divided into mild or moderate and severe TAO groups. Cases were also segregated based on the presence or absence of optic neuropathy. Demographics, smoking status, comorbidities, thyroid hormonal status, thyroid autoantibody levels, and clinical presentations were assessed.

Results

A total of 99 patients (83 with mild to moderate courses and 16 with severe courses; 90 without optic neuropathy and 9 with optic neuropathy) were included in this study. On multiple logistic regression analysis, smoking status was a predictive risk factor for a severe course of TAO and the development of optic neuropathy (odds ratios = 6.57 and 10.00, respectively). Other factors such as age, gender, free T4 level, thyroid binding-inhibiting immunoglobulin, and a history of diabetes were not predictive of severe TAO or optic neuropathy.

Conclusions

Although various factors may influence the severity of TAO and the development of optic neuropathy, this study showed that smoking was a risk factor for severe TAO and the development of optic neuropathy. Therefore, it is important for patients with Graves' disease to refrain from smoking. Frequent and careful observation should also be performed in current smokers, as TAO patients who smoke are susceptible to a severe course and/or optic neuropathy.

Thyroid-associated ophthalmopathy after treatment for Graves' hyperthyroidism with antithyroid drugs or iodine-131

CONTEXT

Previous randomized trials have suggested an association between radioiodine treatment for Graves' hyperthyroidism and thyroid-associated ophthalmopathy (TAO).

OBJECTIVES

The aim of the study was to compare the occurrence of worsening or development of TAO in patients who were treated with radioiodine or antithyroid drugs.

DESIGN

We conducted a randomized trial (TT 96) with a follow-up of 4 yr. PATIENTS, SETTING, AND INTERVENTION: Patients with a recent diagnosis of Graves' hyperthyroidism were randomized to treatment with iodine-131 (163 patients) or 18 months of medical treatment (150 patients). Early substitution with T(4) was given in both groups.

MAIN OUTCOME MEASURE

Worsening or development of TAO was significantly more common in the iodine-131 treatment group (63 patients; 38.7%) compared with the medical treatment group (32 patients; 21.3%) (P < 0.001).

RESULTS

The risk for de novo development of TAO was greater in patients treated with iodine-131 (53 patients) than with medical treatment (23 patients). However, worsening of TAO in the 41 patients who had ophthalmopathy already before the start of treatment was not more common in the radioiodine group (10 patients) than in the medical group (nine patients). Smoking was shown to influence the risk of worsening or development of TAO, and smokers treated with radioiodine had the overall highest risk for TAO. However, in the group of smokers, worsening or development of TAO was not significantly associated with the choice of treatment for hyperthyroidism.

CONCLUSIONS

Radioiodine treatment is a significant risk factor for development of TAO in Graves' hyperthyroidism. Smokers run the highest risk for worsening or development of TAO irrespective of treatment modality.

The patient experience of services for thyroid eye disease in the United Kingdom: results of a nationwide survey

BACKGROUND

A recent consensus statement from the European Group on Graves' Orbitopathy recommends referring all patients with thyroid eye disease (TED), except the mildest cases, to a specialist multidisciplinary clinic.

OBJECTIVE

To study the patients' experiences of accessing services for the treatment of TED in the UK.

METHODS

A postal questionnaire survey of 395 members of two patients support organisations for TED in the UK, the TED Charitable Trust and the British Thyroid Foundation.

RESULTS

The response rate was 67%. The majority of responders were females (91%) and aged above 45 (74%). There were delays in the diagnosis and referral. In 26% of responders, the time lapsed from the first symptoms to the diagnosis of TED for over 12 months. There was a wide variation in the type of clinic and healthcare professionals involved in the treatment of TED. Only 25% of the responders attended a specialist TED clinic. Out of these, 33% waited over 6 months from the first consultation with a doctor to being seen at a specialist TED clinic. Only 56% of responders were satisfied with the treatment they received for TED. More responders who had attended a specialist TED clinic were satisfied with the treatment than those who had not attended a specialist clinic (67 vs 52%, P<0.05).

CONCLUSION

Only a minority of patients with TED are treated at a specialist TED clinic in the UK. Those patients who are treated at a specialist TED clinic are more likely to be satisfied with the treatment.

Thyroid-associated orbitopathy: who and how to treat

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

Graves orbitopathy: a perspective

Advances in the past few years have helped clinicians understand some of the pathogenetic mechanisms of Graves orbitopathy (GO), particularly the role of receptors for TSH and insulin-like growth factor I in the orbit. Optimal treatment strategies have been formulated and published by the European Group on Graves' Orbitopathy, which are hoped to improve the management of patients with this condition. The administration of intravenous pulses of steroids has been established as a superior treatment approach compared with other steroid regimens. In addition, orbital radiotherapy was effective in a subgroup of patients with GO who had eye dysmotility. The use of immunotherapies for the treatment of GO is currently being explored; of these, rituximab has emerged as a promising new agent.

Treatment of Graves' hyperthyroidism: evidence-based and emerging modalities

Currently there are three well-established treatment options for hyperthyroid Graves' disease (GD): antithyroid drug therapy with thionamides (ATD), radioactive iodine treatment with (131)I, and thyroid surgery. This article reviews the current evidence so the reader can evaluate advantages and disadvantages of these treatment modalities. Surgery is rarely used, except for patients who have a large goiter or ophthalmopathy. Fewer than 50% of patients treated with ATD remain in long-term remission. Therefore, radioactive iodine is used increasingly. No data as yet support the routine use of biologic therapies (eg, rituximab). Prospective, randomized studies comparing available and any novel therapeutic options for GD are needed. The focus of these studies should include, but not be limited to, cost and quality of life.

Management of Graves' orbitopathy in Latin America: an international questionnaire study compared with Europe

CONTEXT

Management of Graves' orbitopathy (GO) and dysthyroid optic neuropathy (DON) continues to be challenging. Other surveys have been successful in elucidating trends in GO management. Knowledge of current practice by members of the Latin American Thyroid Society (LATS) who manage patients with GO was targeted by distribution of a questionnaire. We compared our results with a previously reported European Thyroid Association (ETA) survey.

OBJECTIVES

To determine how endocrinologists in Latin America access and treat patients with GO and compare the results with the same European survey.

RESULTS

One hundred and two responders representing endocrinologists from 10 countries participated in the survey. Most (57%) participate in a multidisciplinary setting for GO management. Access to a surgeon for orbital decompression was available only 'within months' according to 48.3% of responders. Despite suspected DON, 32.4% were reluctant to recommend urgent referral to an eyecare physician. Steroids were preferred as the first-option therapy by 88.2% of responders (by intravenous route by 57.8% of these). The presence of diabetes reduced the use of steroids to 64.7% (P < 0.001) and increased the use of other immunosuppressive agents (from 1% to 9.8%, P < 0.01). Development of cushingoid features resulted in a reduction in steroid use to 40.2% (P < 0.001), with increased preference for irradiation (from 23.5% to 52.9%, P < 0.001) and nonsteroidal immunosuppressive drugs (from 1% to 10.8%, P < 0.01), along with a nonsignificant trend to higher indication of orbital surgery (from 24.5% to 34.3%).

CONCLUSION

Some potential deficiencies in the diagnosis and management of DON and hyperthyroidism were observed in our survey, highlighting the need for improvement in specialist education and the quality of care offered to patients with GO in Latin America.

The eye and thyroid disease

PURPOSE OF REVIEW

The pathophysiology and optimal management of thyroid eye disease (TED) have not yet been elucidated. Recent studies have increased our knowledge of the disease process and different diagnostic and therapeutic options. This review highlights the recent progress in TED research and identifies areas requiring further advancements.

RECENT FINDINGS

The pathophysiology of TED likely involves genetic and environmental factors, which may potentiate cellular and humoral-mediated inflammation within the orbit. Despite progress in TED research, a target antigen has not been established with certainty. New diagnostic methods and questionnaires are being developed that potentially provide information regarding inflammatory activity of TED. Corticosteroids alone or in combination with orbital radiation may be effective in improving TED symptoms. New immunomodulating therapies may also have a role TED management. Surgery is highly effective for treatment of TED-induced optic nerve compression and for managing the chronic soft tissue changes of TED.

SUMMARY

A unifying hypothesis of TED pathophysiology is elusive. Further bench research into the autoimmune process is needed. In addition, large, prospective, randomized clinical trials based on the inflammatory activity of disease, while difficult to design, are essential to develop a consensus regarding the proper timing and use of anti-inflammatory medications.