The eye and thyroid disease

The Effect of Rho Kinase Inhibitors on In Vitro Human Orbital Preadipocytes

PURPOSE

To identify the effects of Rho Kinase (ROCK) inhibitor medications on human orbital adipogenesis, fibroblast proliferation, and fibrosis.

METHODS

Orbital adipose tissue was obtained from patients with Graves' ophthalmopathy (GO) as well as controls (non-GO or normal) after informed consent was done. These tissue samples were cultured and adipogenesis was initiated. Levels of Rho Kinase as well as cellular mediators of orbital inflammation and fibrosis. The same cultures and measurements were then repeated with the use of a ROCK inhibitor (KD025-ROCK2) to assess for changes in adipogenesis as well as markers associated with inflammation and fibrosis.

RESULTS

Rho Kinase levels in GO tissue were more highly expressed than in controls. These levels were suppressed with the use of the ROCK inhibitor KD025. There was a dose-dependent reduction in differentiation of orbital adipocytes with the use of KD025. KD025 reduced the levels of fibrosis-related gene expression. Finally, there was a significant reduction of transforming growth factor beta mediated phosphorylation signaling pathways in the KD025-treated GO tissue.

CONCLUSION

This study shows that the ROCK inhibitor, KD025, helps to reduce the expression of ROCK in GO tissue along with reducing orbital adipocyte differentiation as well as cell mediators involved in fibrosis that occurs in GO.

Non-coding RNA-mediated epigenetic alterations in Grave's ophthalmopathy: A scoping systematic review

Background

It is becoming more and more apparent that Grave's Ophthalmopathy (GO) pathogenesis may be aided by epigenetic processes such as DNA methylation modifications, histone tail covalent modifications, and non-coding RNA (ncRNA)-based epigenetic processes. In the present study, we aimed to focus more on the miRNAs rather than lncRNAs due to lack of investigations on these non-coding RNAs and their role in GO's pathogenesis.

Methods

A six-stage methodology framework and the PRISMA recommendation were used to conduct this scoping review. A comprehensive search was conducted across seven databases to discover relevant papers published until February 2022. The data extraction separately, and quantitative and qualitative analyses were conducted.

Results

A total of 20 articles were found to meet inclusion criteria. According to the results, ncRNA were involved in the regulation of inflammation (miR-146a, LPAL2/miR-1287-5p axis, LINC01820:13/hsa miR-27b-3p axis, and ENST00000499452/hsa-miR-27a-3p axis), regulation of T cell functions (miR-146a/miR-183/miR-96), regulation of glycosaminoglycan aggregation and fibrosis (miR-146a/miR-21), glucocorticoid sensitivity (miR-224-5p), lipid accumulation and adipogenesis (miR-27a/miR-27b/miR-130a), oxidative stress and angiogenesis (miR-199a), and orbital fibroblast proliferation (miR-21/miR-146a/miR-155). Eleven miRNAs (miR-146a/miR-224-5p/miR-Let7d-5p/miR-96-5p/miR-301a-3p/miR-21-5p) were also indicated to have the capacity to be used as biomarkers.

Conclusions

Regardless of the fact that there is significant documentation of ncRNA-mediated epigenetic dysfunction in GO, additional study is needed to thoroughly comprehend the epigenetic connections concerned in disease pathogenesis, paving the way for novel diagnostic and prognostic tools for epigenetic therapies among the patients.

Update on the surgical management of Graves' orbitopathy

Graves' orbitopathy (GO) is a complex autoimmune disorder of the orbit that causes the eye to appear disfigured. GO is typically associated with Graves' disease, an inflammatory autoimmune condition that is caused by thyrotropin receptor autoantibodies. Although our knowledge of the pathophysiology of GO has improved, its exact pathogenesis remains unclear. Some patients suffer from disfigurement, double vision, and even vision loss rather than hyperthyroidism. The disease severity and activity prompt different treatments, as the signs of GO are heterogeneous, so their management can be very complex. Despite medical advances, the first-line treatment for moderate-to-severe active GO is still glucocorticoids, while surgery can be critical for the treatment of chronic inactive GO. Surgery is sometimes required in the acute phase of the disease when there is an immediate risk to vision, such as in dysthyroid optic neuropathy. Most surgeries for GO are rehabilitative and subdivided into three categories: decompression, strabismus repair, and lid surgery. This review is a basic overview of the field, with up-to-date knowledge of the surgical techniques for GO. We review and summarize recent literature on the advances in surgery for GO to provide up-to-date insights on the optimal surgical treatment for GO.

Optic disc, macula and ganglion cell layer measurements obtained with optical coherence tomography in patients with thyroid disorder

Purpose: The aim of this study was to compare retinal nerve layer thickness, central macula thickness and ganglion cell layer measurements using optical coherence tomography (OCT) between thyroid patients and age- and sex-matched healthy controls. Materials and Methods: Eighty eyes of 80 patients in the thyroid patient group and 48 eyes of 48 patients in the control group were included in the study. After evaluating the exclusion criteria, visual acuity, anterior segment biomicroscopy, intraocular pressure, fundoscopy and spectral field optic coherence tomography (SF-OCT) imaging tests were performed on all patients included in the study. These data have been recorded. Central macular thickness (CMT), retinal nerve fiber layer (RNFL) and ganglion cell complex (GCC) measurements were evaluated by statistical methods for both groups. Results: There was no statistically significant difference between the demographic data of the groups included in the study. IOP measurements were found to be statistically significantly higher in the patient group compared to the control group. CMT values were 258.2±16.1 µm in the patient group and 273.1±23.8 µm in the control group, and statistically significant differences were observed between the groups. Conclusion: The findings supports that changes in the optic nerve and macula develop before vision loss in TO patients compared to the healthy control group. We can follow TO patients more objectively and reliably and make treatment planning more accurately by adding OCT, which is a noninvasive test, to our clinical practice, since structural changes develop before functional deterioration in TO patients.

Metformin Attenuates Inflammation and Fibrosis in Thyroid-Associated Ophthalmopathy

The pathogenesis of thyroid-associated ophthalmopathy (TAO) is still unclear, and therapeutic drugs have great limitations. As metformin has multiple therapeutic effects in many autoimmune diseases, we explored the effects of metformin on TAO in an in vitro fibroblast model. We used orbital connective tissues and fibroblasts that were obtained from TAO patients and normal controls. The activity of adenosine monophosphate-activated protein kinase (AMPK) and the levels of inflammatory or fibrotic factors were examined by immunofluorescence (IF) and immunohistochemistry (IHC). Quantitative real-time polymerase chain reaction (qPCR), cytokine quantification by enzyme-linked immunosorbent sssay (ELISA), IF, and western blotting (WB) were used to measure the expression of factors related to inflammation, fibrosis, and autophagy. To determine the anti-inflammatory and antifibrotic mechanisms of metformin, we pretreated cells with metformin, 5-aminoimidazole-4-carboxamide 1-β-D-ribofuranoside (AICAR, an AMPK activator) or compound C (CC, an AMPK inhibitor) for 24 h and used WB to verify the changes in protein levels in the AMPK/mammalian target of rapamycin (mTOR) pathway. We determined that the low activity of AMPK in the periorbital tissue of TAO patients may be closely related to the occurrence and development of inflammation and fibrosis, and metformin exerts multiple effects by activating AMPK in TAO. Furthermore, we suggest that AMPK may be a potential target of TAO therapy.

Therapeutic Effect of Gypenosides on Antioxidant Stress Injury in Orbital Fibroblasts of Graves’ Orbitopathy

Purpose

To examine the impact of gypenosides (Gyps) on oxidative stress damage of orbital fibroblasts (OFs) from Graves' ophthalmopathy (GO) patients.

Methods

The relationship between Gyps and GO oxidative stress was understood by bioinformatics analysis. Orbital connective tissues of GO and non-GO patients were obtained for primary OF culture. The proliferation level of OFs was measured by Cell Counting Kit-8 method, and the appropriate intervention concentration of Gyps and H₂O₂ was obtained. The expression of apoptosis-related protein mRNA was analyzed by RT-qPCR technique. ROS and SOD test suites were employed to detect the oxidative stress level in OFs. Flow cytometry apoptosis detection, TUNEL detection, and lactate dehydrogenase detection were used to analyze the level of apoptosis. Western blotting detection was utilized to examine the regulatory pathway of oxidative stress, apoptosis, and autophagy-related proteins. The changes of cell morphology, autophagosome, and autophagy lysosome were observed by transmission electron microscope.

Results

The suitable intervention concentration of Gyps is 100 μg/mL, and the suitable intervention concentration of high concentration H₂O₂ is 350 μM. In comparison with the blank control group, the H₂O₂ intervention group enhanced the expression of apoptosis-related mRNA, the expression of ROS and SOD, the apoptosis rate, the expression of autophagy activation-related protein and Nrf2/ERK/HO-1 protein, and the number of autophagosomes and autophagy lysosomes. Compared with H₂O₂ intervention group, the expression of apoptosis-related mRNA decreased, ROS expression decreased, SOD expression increased, apoptosis rate decreased, autophagy activation-related protein expression decreased, Nrf2/ERK/HO-1 protein expression increased, and the quantity of autophagosomes and autophagy lysosomes decreased in H₂O₂ + Gyps intervention group.

Conclusion

Gyps can decrease the oxidative stress level of OFs generated by H₂O₂, reduce cell autophagy, and reduce apoptosis. Gyps may regulate the oxidative stress response of OFs in GO patients via the Nrf2/ERK/HO-1 signaling pathway.

Thinking inside the box: Current insights into targeting orbital tissue remodeling and inflammation in thyroid eye disease

Thyroid eye disease (TED) is an autoimmune disorder that manifests in the orbit. In TED, the connective tissue behind the eye becomes inflamed and remodels with increased fat accumulation and/or increased muscle and scar tissue. As orbital tissue expands, patients develop edema, exophthalmos, diplopia, and optic neuropathy. In severe cases vision loss may occur secondary to corneal scarring from exposure or optic nerve compression. Currently there is no cure for TED, and treatments are limited. A major breakthrough in TED therapy occurred with the FDA approval of teprotumumab, a monoclonal insulin-like growth factor 1 receptor (IGF1R) blocking antibody. Yet, teprotumumab therapy has limitations, including cost, infusion method of drug delivery, variable response, and relapse. We describe approaches to target orbital fibroblasts and the complex pathophysiology that underlies tissue remodeling and inflammation driving TED. Further advances in the elucidation of the mechanisms of TED may lead to prophylaxis based upon early biomarkers as well as lead to more convenient, less expensive therapies.

Eye symptoms in patients with benign thyroid diseases

Thyroid diseases may cause a variety of functional and structural body changes, including eye and vision abnormalities, which can have a negative impact on a patient’s well-being. However, only a few studies on the impact of other benign thyroid diseases on the visual process are available in the literature. In this study, using the Polish version of the thyroid-specific quality of life (ThyPROpl) questionnaire, we aimed to determine the self-reported influence of benign thyroid diseases (e.g., nodular goiter, toxic nodular goiter, Graves’ disease, thyroid orbitopathy, Hashimoto’s thyroiditis, and surgical hypothyroidism) on patients’ eyes and vision. This was a prospective study. In total, 374 randomly selected euthyroid patients and 255 control subjects responded to the ThyPROpl questionnaire and the results were evaluated. Nearly 69% of the respondents reported that the most frequent condition was “reduced sight.” Men most often reported wet/tearing eyes (66%). The occurrence of eyelid sacks or swollen eyelids (64%), ophthalmalgia (62%), and eye dryness (61%) was marked almost as often. In total, 29% of the patients reported diplopia, and it was found to be most prevalent among those with thyroid orbitopathy. Other complaints were similarly prevalent among all the subgroups. A positive correlation was also observed between the scores of the “eye symptoms” and other ailments. Except for swelling around the lower eyelids, patients with thyroid diseases more frequently experienced all of the ocular complaints analyzed in this study compared with controls. This study showed that eye complaints are common in patients with benign thyroid diseases and ocular disturbances have a negative impact on the overall quality of life of patients.

Anti-inflammatory and Antioxidant Effects of Selenium on Orbital Fibroblasts of Patients With Graves Ophthalmopathy

PURPOSE

In the present study, the authors investigated the effects of selenium on inflammation, hyaluronan production, and oxidative stress in primary cultured orbital fibroblasts of patients with Graves ophthalmopathy (GO).

METHODS

Orbital adipose/connective tissue specimens were obtained during the course of orbital surgery for patients with GO (n = 7) and other noninflammatory problems (n = 5). After incubation with various concentrations of sodium selenite for 48 hours, supernatants from primary cultures were collected. Hyaluronan and cytokine levels were measured using commercially available enzyme-linked immunosorbent assay kits. To determine the effect of selenium on reactive oxygen species (ROS) production stimulated by H2O2 (100 μM) for 30 minutes, the cells were pretreated with various concentrations of sodium selenite for 60 minutes.

RESULTS

Interleukin (IL)-6 and tumor necrosis factor-alpha levels were significantly higher in orbital fibroblasts of patients with GO than in orbital fibroblasts of control patients. Hyaluronan production was suppressed by selenium in cultured orbital fibroblasts of patients with GO. Inflammatory cytokines such as IL-1α, IL-8, and tumor necrosis factor-alpha were suppressed by selenium in cultured orbital fibroblasts of patients with GO. IL-1β and IL-6 were not suppressed by selenium in cultured orbital fibroblasts of patients with GO. Selenium pretreatment reduced intracellular ROS generation stimulated by H2O2 in cultured orbital fibroblasts of patients with GO.

CONCLUSIONS

In conclusion, hyaluronan production, inflammatory cytokines, and intracellular ROS generation were suppressed by selenium in cultured orbital fibroblasts of patients with GO. Several inflammatory cytokines may be suppressed by selenium in cultured orbital fibroblasts of patients with GO. This study provide the basis for use of selenium in the treatment of GO.

MicroRNA-130a Is Elevated in Thyroid Eye Disease and Increases Lipid Accumulation in Fibroblasts Through the Suppression of AMPK

Purpose

Thyroid eye disease (TED) is a condition that causes the tissue behind the eye to become inflamed and can result in excessive fatty tissue accumulation in the orbit. Two subpopulations of fibroblasts reside in the orbit: those that highly express Thy1 (Thy1+) and those with little or no Thy1 (Thy1–). Thy1– orbital fibroblasts (OFs) are more prone to lipid accumulation than Thy1+ OFs. The purpose of this study was to investigate the mechanisms whereby Thy1– OFs more readily accumulate lipid.

Methods

We screened Thy1+ and Thy1– OFs for differences in microRNA (miRNA) expression. The effects of increasing miR-130a levels in OFs was investigated by measuring lipid accumulation and visualizing lipid deposits. To determine if adenosine monophosphate-activated protein kinase (AMPK) is important for lipid accumulation, we performed small interfering RNA (siRNA)-mediated knockdown of AMPKβ1. We measured AMPK expression and activity using immunoblotting for AMPK and AMPK target proteins.

Results

We determined that miR-130a was upregulated in Thy1– OFs and that miR-130a targets two subunits of AMPK. Increasing miR-130a levels enhanced lipid accumulation and reduced expression of AMPKα and AMPKβ in OFs. Depletion of AMPK also increased lipid accumulation. Activation of AMPK using AICAR attenuated lipid accumulation and increased phosphorylation of acetyl-CoA carboxylase (ACC) in OFs.

Conclusions

These data suggest that when Thy1– OFs accumulate in TED, miR-130a levels increase, leading to a decrease in AMPK activity. Decreased AMPK activity promotes lipid accumulation in TED OFs, leading to excessive fatty tissue accumulation in the orbit.

Glycogen Synthase Kinase-3β Mediates Proinflammatory Cytokine Secretion and Adipogenesis in Orbital Fibroblasts from Patients with Graves' Orbitopathy

Purpose

We sought to determine the role of glycogen synthase kinase-3β (GSK-3β) in the pathogenesis of Graves’ orbitopathy(GO).

Methods

Expression of the GSK-3β gene in whole orbital tissue explants was compared between GO and non-GO donors using quantitative real-time PCR (RT-PCR). The expression of proinflammatory molecules in the presence of the GSK-3β inhibitor CHIR 99021 was analyzed using RT-PCR, western blot, and ELISA. Adipogenic differentiation was identified using Oil Red O staining, and the levels of peroxisome proliferator activator gamma (PPARγ) and CCAAT-enhancer-binding proteins (C/EBPs) α and β were determined by western blot.

Results

The expression of GSK-3β was significantly higher in GO tissues than in control tissues. The addition of CHIR 99021 led to a decrease in the active form of the kinase in which the Y216 residue is phosphorylated. When GO and non-GO fibroblasts were stimulated with IL-1β or TNF-α, IL-6, IL-8, intercellular adhesion molecule-1 (ICAM-1), cyclooxygenase-1 (COX-1), and monocyte chemoattractant protein 1 (MCP-1) showed increased production, which was blunted when CHIR 99021 was added. The activation of Akt, PI3K, nuclear factor (NF)-κB, Erk, Jnk, and p38 kinase by IL-1β and TNF-α was diminished with CHIR 99021 in GO cells. A decrease in lipid droplets and expression of PPARγ and c/EBPα and -β was noted in fibroblasts treated with CHIR 99021 during adipocyte differentiation. The inhibition of Wnt and β-catenin in adipogenesis was reversed by CHIR 99021.

Conclusions

GSK-3β plays a significant role in GO pathogenesis. The inhibition of the kinase attenuated the proinflammatory cytokines production and fibroblast differentiation into adipocytes. GSK-3β may be a potential target for anti-inflammatory and anti-adipogenic treatment of GO.

Reduced macular inner retinal thickness and microvascular density in the early stage of patients with dysthyroid optic neuropathy

Background

The goal was to investigate changes of the inner intra-retinal layer thicknesses and retinal capillary density (RCD) around the macula in thyroid-associated ophthalmopathy (TAO) patients with or without dysthyroid optic neuropathy (DON).

Methods

Forty-four TAO patients including 23 non-DON and 21 DON patients, and 38 healthy participants were enrolled. Spectral domain optical coherence tomography equipped with Angiovue was used to obtain three-dimensional retinal thickness maps and microvascular images of the superficial and deep retinal capillary layers (SRCL and DRCL, respectively) around the macula. Quantitative analyses were performed using a custom automated algorithm.

Results

The thicknesses of the nerve fiber layer, ganglion cell layer + inner plexiform layer, and ganglion cell complex (GCC) as well as the RCDs in the SRCL and DRCL in both TAO groups were significantly decreased compared to the controls. In addition, the RCDs in DRCL of the DON group were further decreased compared to the non-DON group. GCC thickness in both TAO groups was positively correlated with the RCDs of the SRCL in the total annular zone and in the temporal, inferior, and nasal sectors. The areas under the receiver operating characteristic curves for the GCC thickness combined with the RCD were generally larger than those of each single indicator.

Conclusions

Thinned inner intra-retinal layers and decreased RCDs in the TAO patients without DON revealed that morphological changes might precede visual dysfunction. The composite index of the retinal structure and the microvascular density might be valuable in the diagnosing, monitoring, and intervention for early DON.

TSHR Signaling Stimulates Proliferation Through PI3K/Akt and Induction of miR-146a and miR-155 in Thyroid Eye Disease Orbital Fibroblasts

Purpose

To investigate the molecular pathways that drive thyroid stimulating hormone receptor (TSHR)–induced cellular proliferation in orbital fibroblasts (OFs) from thyroid eye disease (TED) patients.

Methods

Orbital fibroblasts from TED and non-TED patients were treated with TSH and changes in gene expression and proliferation were measured. To determine the role of TSHR, TSHR-specific siRNA was used to deplete TSHR levels. Proliferation was measured by bromodeoxyuridine (BrdU) incorporation. PI3K/Akt activation was analyzed by Western blot. The PI3K inhibitor LY294002 was used to investigate PI3K/Akt signaling in OF proliferation. Expression of TSHR, inflammatory cytokines, proliferation related genes and miR-146a and miR-155 were measured by qPCR.

Results

Orbital fibroblasts from TED patients proliferate significantly more than non-TED OFs in response to TSH. TSH-induced proliferation was dependent upon TSHR expression and required the PI3K/Akt signaling cascade. TSHR activation stimulated miR-146a and miR-155 expression. TED OFs produced significantly more miR-146a and miR-155 than non-TED OFs. MiR-146a and miR-155 targets, ZNRF3 and PTEN, which both limit cell proliferation, were decreased in TSH treated OFs.

Conclusions

These data reveal that TSHR signaling in TED OFs stimulates proliferation directly through PI3K/Akt signaling and indirectly through induction of miR-146a and miR-155. MiR-146a and miR-155 enhance TED OF proliferation by reducing expression of target genes that normally block cell proliferation. TSHR-dependent expression of miR-146a and miR-155 may explain part of the fibroproliferative pathology observed in TED.

Fibroblast Growth Factor Receptor Inhibitors Reduce Adipogenesis of Orbital Fibroblasts and Enhance Myofibroblastic Differentiation in Graves' Orbitopathy

Purpose: Orbital fibroblasts are involved in pathogenesis of Graves' orbitopathy (GO). Fibroblast growth factor (FGF) affects fibroblasts of GO. This study aims to investigate the roles of FGF and FGF receptor (FGFR) in GO.Methods: Serum FGF proteins and orbital fibroblast FGFR proteins and mRNAs were measured in GO patients and controls. Orbital fibroblasts of GO were cultured and accessed for changes in proliferation (by nuclei number and MTT), myofibroblastic differentiation (by α-SMA), and adipogenesis (by oil droplets using Oil Red O stain) under FGF1 with or without FGFR inhibitors (FGFRi).Results: Serum FGF1 and FGF2 were increased in GO patients. FGFR1 was the most abundantly expressed FGFR in GO orbital fibroblasts. FGF1 increased GO fibroblast proliferation/adipogenesis and suppressed myofibroblastic differentiation, while FGFRi reversed these effects.Conclusion: FGF signaling may be involved in GO pathogenesis. Manipulation of FGF-FGFR pathway for GO treatment is worthy of further investigation.Registration number on Clinicaltrials.gov: NCT03324022.

Correlation Between Optical Coherence Tomography and Magnetic Resonance Imaging of Rectus Muscle Thickness Measurements in Graves' Ophthalmopathy

PURPOSE

To assess the correlation between optical coherence tomography (OCT) and magnetic resonance imaging (MRI) measurements of extraocular rectus muscle thickness in patients with Graves' ophthalmopathy.

METHODS

This was a cross-sectional observational study conducted in 62 eyes of 31 patients with Graves' ophthalmopathy. The disease phase was inactive in 20 patients and active in the remaining 11. The OCT measurements obtained were: medial rectus thickness at 7.2 and 9.2 mm from the limbus and lateral rectus thickness at 8.5 mm from the limbus. MRI measurements were maximum transversal diameter (T-MRI), craniocaudal diameter (CC-MRI), and muscle area (A-MRI).

RESULTS

For the whole patient cohort, correlation emerged between the OCT-MR and T-MRI measurements (R = 0.428 to 0.576; P ≤ .002), A-MRI (R = 0.562 to 0.674; P < .001), and CC-MRI (R = 0.286 to 0.293; P ≤ .046). In patients with clinically active Graves' ophthalmopathy, correlations with T-MRI (R = 0.576 to 0.604; P ≤ .010) and A-MRI (R = 0.678 to 0.706; P < .001) were higher. No correlations were detected between OCT and MRI measurements of lateral rectus thickness (P ≥ .177), regardless of disease phase.

CONCLUSIONS

The correlations observed suggest OCT could be a complementary assessment or screening method to detect thickening of the anterior portion of the medial rectus muscle in patients with Graves' ophthalmopathy, which may be especially useful when MRI is not available. [J Pediatr Ophthalmol Strabismus. 2019;56(5):319-326.].

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

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

Optical Coherence Tomography Thickness Measurements of the Extraocular Rectus Muscle Tendons in Graves' Ophthalmopathy

PURPOSE

To examine extraocular rectus muscle tendons in patients with Graves' ophthalmopathy using optical coherence tomography (OCT).

METHODS

This was a cross-sectional observational study conducted with 55 healthy controls, 45 patients with clinically inactive Graves' ophthalmopathy, and 12 patients with clinically active Graves' ophthalmopathy. Scanning was performed at the 3- and 9-o'clock positions. The medial rectus tendon thickness was measured at 7.2 and 9.2 mm from the limbus and the lateral rectus tendon thickness was measured at 8.5 and 10.5 mm from the limbus.

RESULTS

The 9.2-mm medial rectus, 8.5-mm lateral rectus, and 10.5-mm lateral rectus tendons were thicker in the inactive Graves' ophthalmopathy group than the control group (240 ± 70, 231 ± 63, and 228 ± 54 µm vs 201 ± 71, 199 ± 53, and 200 ± 32 µm, respectively; P ≤ .011), whereas the 8.5-mm lateral rectus and 9.2-mm medial rectus tendons were thicker in patients with active Graves' ophthalmopathy than patients with inactive Graves' ophthalmopathy (274 ± 77 and 283 ± 68 µm vs 231 ± 63 and 240 ± 70 µm, respectively; P ≤ .048). A correlation was detected between lateral rectus and medial rectus tendon thicknesses and the Graves' ophthalmopathy clinical activity score (R = 0.252, P = .035; and R = 0.291, P = .013, respectively).

CONCLUSIONS

OCT emerged as an accurate method for measuring medial rectus and lateral rectus tendon thicknesses in patients with Graves' ophthalmopathy. The imaging tool was able to detect thicker horizontal rectus tendons in patients with inactive Graves' ophthalmopathy than in controls, and in patients with active compared to inactive disease. [J Pediatr Ophthalmol Strabismus. 2018;55(6):356-362.].

Autoimmune thyroiditis and central serous chorioretinopathy may have a relation

Autoimmune thyroiditis (AT) is an important cause of hypothyroidism, and central serous chorioretinopathy (CSCR) is an independent disease of the choroid and retina that leads to accumulation of fluid beneath the retina. While AT has been associated with multiple antibodies, CSCR is still regarded as idiopathic despite extensive research. We hypothesize a causative association between these 2 conditions on the basis of our experience of a case where both CSCR and AT presented simultaneously and depicted a parallel course. CSCR was documented with retinal imaging while AT was documented with serum antibody titers. Further, we discuss the possible mechanisms that may be involved in this intriguing association.

Biguanides Metformin and Phenformin Generate Therapeutic Effects via AMP-Activated Protein Kinase/Extracellular-Regulated Kinase Pathways in an In Vitro Model of Graves' Orbitopathy

BACKGROUND

It was hypothesized that the biguanides metformin and phenformin, which are anti-hyperglycemic drugs used for diabetes mellitus, would have therapeutic effects in an in vitro model of Graves' orbitopathy (GO). Because adipogenesis, hyaluronan production, and inflammation are considered important in the pathogenesis of GO, this study aimed to determine the therapeutic effects and underlying mechanisms of biguanides on these parameters.

METHODS

In vitro experiments were performed using primary cultured orbital fibroblasts from patients with GO. Orbital preadipocyte fibroblasts were allowed to differentiate into adipocytes and were treated with various concentrations of metformin or phenformin. Oil Red O staining was performed to evaluate lipid accumulation within the cells. Western blot analysis was used to measure the expression of adipogenic transcription factors and the phosphorylation of AMP-activated protein kinase and mitogen-activated protein kinase signaling proteins. Hyaluronan production was measured using enzyme-linked immunosorbent assay, and mRNA levels of proinflammatory molecules were determined using real-time polymerase chain reaction after interleukin (IL)-1β stimulation with or without biguanide treatment.

RESULTS

Lipid accumulation during adipogenesis in GO orbital fibroblasts was dose-dependently suppressed by both metformin and phenformin. Adipocyte differentiation was attenuated, and the adipogenic transcription factors peroxisome proliferator-activated receptor γ and CCAAT-enhancer-binding proteins-α/β were downregulated. Furthermore, metformin and phenformin increased the phosphorylation of AMP-activated protein kinase and suppressed extracellular-regulated kinase activation. The IL-1β-induced hyaluronan production and mRNA expression of IL-6, cyclooxygenase-2, and intercellular adhesion molecule-1 were also significantly suppressed after metformin or phenformin co-treatment.

CONCLUSIONS

The present study indicates that the biguanides metformin and phenformin exert an anti-adipogenic and inhibitory effect on hyaluronan production and expression of pro-inflammatory molecules in GO orbital fibroblasts, suggesting that they could potentially be used for the treatment of GO.

Optic nerve compression: the role of the lamina cribrosa and translaminar pressure

AIM

To describe the morphological changes of the lamina cribrosa (LC) in patients with optic nerve compression.

METHODS

Cross-sectional study. Twenty eyes with optic nerve compression, affected by Graves' ophthalmopathy (GO) were compared with 18 refractive error-matched healthy eyes. The following examinations were performed: best-corrected visual acuity (BCVA), intraocular pressure, optic nerve echography, visual field, SD-OCT including the retinal nerve fiber layer (RNFL), ganglion cell complex (GCC), and LC thickness and extent.

RESULTS

A-scan revealed significant differences in the subarachnoid space (SAS) between the affected and control groups. LC thickness and LC area were 233 µm (SD 23) and 0.41 mm² (SD 0.19), respectively. Average GCC thickness (P=0.0005), LC thickness (P=0.001), MD (P=0.001) and PSD (P=0.001) differed significantly between the two groups; whereas LC area (P=0.2) and average RFNL (P=0.1) did not.

CONCLUSION

Optic nerve compression reduces the SAS thereby altering the morphology of LC thickness and causing GCC damage.

Quantitative Analysis of Inflammation in Orbital Fat of Thyroid-associated Ophthalmopathy Using MRI Signal Intensity

We quantitatively analyzed inflammation in orbital fat from cases of thyroid-associated ophthalmopathy (TAO) using short-tau inversion recovery (STIR) sequences from magnetic resonance imaging. The signal intensity ratios (SIRs) of orbital fat as well as the superior rectus (SR), inferior rectus (IR), lateral rectus (LR), medial rectus (MR), and superior oblique (SO) muscles on STIR images were measured in 70 eyes from 70 treatment-naive TAO patients (active TAO group, 19 patients; inactive TAO group, 51 patients) and 20 eyes from 20 controls. The mean SIR in the active TAO group was significantly higher than that in the inactive TAO group and controls (P < 0.001). The SIR of orbital fat in all TAO patients was significantly (P < 0.001) positively correlated with that of the extraocular muscles: SR (r = 0.64), IR (r = 0.55), LR (r = 0.58), MR (r = 0.71), and SO (r = 0.65). The SIR of orbital fat had a significant positive correlation with the CAS (r = 0.53, P < 0.001). The measurements of SIRs in orbital fat may be useful in evaluating the activity in tissues of TAO patients.

Identification and Functional Characterization of ST3GAL5 and ST8SIA1 Variants in Patients with Thyroid-Associated Ophthalmopathy

PURPOSE

This study was conducted to identify and to functionally characterize genetic variants in ST3GAL5 and ST8SIA1 in Korean patients with thyroid-associated ophthalmopathy (TAO).

MATERIALS AND METHODS

Genetic analyses were conducted using DNA samples from TAO patients (n=50) and healthy subjects (n=48) to identify TAO-specific genetic variants of ST3GAL5 or ST8SIA1. The effect of each genetic variant on the transcription or expression of these genes was examined. Additionally, correlations between functional haplotypes of ST3GAL5 or ST8SIA1 and clinical characteristics of the patients were investigated.

RESULTS

Six promoter variants and one nonsynonymous variant of ST3GAL5 were identified, and four major promoter haplotypes were assembled. Additionally, three promoter variants and two major haplotypes of ST8SIA1 were identified. All ST3GAL5 and ST8SIA1 variants identified in TAO patients were also found in healthy controls. Promoter activity was significantly decreased in three promoter haplotypes of ST3GAL5 and increased in one promoter haplotype of ST8SIA1. Transcription factors activating protein-1, NKX3.1, and specificity protein 1 were revealed as having roles in transcriptional regulation of these haplotypes. The nonsynonymous variant of ST3GAL5, H104R, did not alter the expression of ST3GAL5. While no differences in clinical characteristics were detected in patients possessing the functional promoter haplotypes of ST3GAL5, exophthalmic values were significantly lower in patients with the ST8SIA1 haplotype, which showed a significant increase in promoter activity.

CONCLUSION

These results from genotype-phenotype analysis might suggest a possible link between the ST8SIA1 functional promoter haplotype and the clinical severity of TAO. However, further studies with larger sample sizes are warranted.

The Aryl Hydrocarbon Receptor and Its Ligands Inhibit Myofibroblast Formation and Activation: Implications for Thyroid Eye Disease

Thyroid eye disease (TED) is a degenerative disease that manifests with detrimental tissue remodeling, myofibroblast accumulation, and scarring in the orbit of affected individuals. Currently, there are no effective therapies for TED that target or prevent the excessive tissue remodeling caused by myofibroblast formation and activation. The canonical cytokine that induces myofibroblast formation is transforming growth factor (TGF)-β. The TGF-β signaling pathway is influenced by aryl hydrocarbon receptor (AHR) signaling pathways. We hypothesized that AHR agonists can prevent myofibroblast formation in fibroblasts from patients with TED, and thus AHR ligands are potential therapeutics for the disease. Orbital fibroblasts explanted from patients with TED were treated with TGF-β to induce myofibroblast formation, contraction, and proliferation. We found that AHR ligands prevent TGF-β-dependent myofibroblast formation, and this ability is dependent on AHR expression. The AHR and AHR ligands block profibrotic Wnt signaling by inhibiting the phosphorylation of GSK3β to prevent myofibroblast formation. These results provide new insight into the molecular pathways underlying orbital scarring in TED. These novel studies highlight the potential of the AHR and AHR ligands as future therapeutic options for eye diseases and possibly also for other scarring conditions.

The relationship between serum adipocytokines and Graves' ophthalmopathy: A hospital-based study

Adipocytokines are thought to be associated with inflammatory disorders and autoimmune diseases. However, limited information is available on the relationship between serum adipocytokine levels, Graves' disease (GD), and Graves' ophthalmopathy (GO). The present study examined the relationship between serum adipocytokine levels and GD and GO. A total of 80 patients with GD participated in this study. The medical records of patients were reviewed retrospectively. GO activity was assessed using the clinical activity score (CAS). GO severity was assessed by the modified NOSPECS classification and included soft tissue involvement, proptosis, and extraocular muscle involvement. Serum adiponectin, leptin, resistin, and retinol-binding protein 4 (RBP-4) levels were measured using commercially available enzyme-linked immunosorbent assays. The prevalence of GO was 36.3%. Serum adiponectin, leptin, and resistin levels were significantly higher in patients with GO than in those without GO. The CAS was positively correlated with serum adiponectin and leptin levels. The total eye score was positively correlated with serum adiponectin, leptin, resistin, and RBP-4 levels. A multivariate analysis revealed that serum leptin and resistin levels were associated with the presence of GO after adjusting for clinical factors. Free thyroxine was negatively correlated with serum leptin level. These results suggest that adipocytokines, such as leptin and resistin, may play a role in inflammatory and autoimmune processes of GD and GO. Future studies with larger numbers of patients are required to establish relationships between serum adipocytokines levels and GO and ascertain the role of adipocytokines in GD and GO.

Relationship between magnetic resonance imaging signal intensity and volume of extraocular muscles in thyroid-associated ophthalmopathy with methylprednisolone pulse therapy

Purpose

To characterize the relationship between inflammation and swelling of extraocular muscles in thyroid-associated ophthalmopathy before and after methylprednisolone pulse therapy.

Methods

The signal intensities and volumes of the superior rectus (SR), inferior rectus (IR), lateral rectus (LR), medial rectus (MR), and superior oblique (SO) muscles were measured with magnetic resonance imaging in 25 eyes of 25 patients with thyroid-associated ophthalmopathy in the acute inflammatory phase before and after methylprednisolone pulse therapy. The signal intensity ratios (SIRs) of muscles and brain white matter were calculated.

Result

The mean SIRs before treatment were 2.28±0.74 in SR, 2.66±0.57 in IR, 2.03±0.42 in LR, 2.45±0.49 in MR, and 1.98±0.48 in SO muscles. The mean SIRs after treatment were 1.82±0.62, 1.84±0.52, 1.70±0.35, 1.95±0.46, and 1.60±0.36, respectively. The mean volumes (cm³) before treatment were 1.35±0.67 in SR, 1.21±0.39 in IR, 0.66±0.13 in LR, 0.94±0.31 in MR, and 0.58±0.14 in SO muscles. Those after treatment were 1.12±0.45, 0.91±0.31, 0.61±0.12, 0.85±0.28, and 0.49±0.11, respectively. The SIRs showed significantly positive correlations with volumes both before and after treatment in SR muscles (before, r=0.77; after, r=0.69), IR muscles (before, r=0.65; after, r=0.60), MR muscles (before, r=0.69; after, r=0.73), and SO muscles (before, r=0.52; after, r=0.50) (P<0.01 for all correlations).

Conclusion

Swelling reflected the inflammation in extraocular muscles of thyroid-associated ophthalmopathy both before and after treatment.

Development of Thyroid-Associated Ophthalmopathy in Patients Who Underwent Total Thyroidectomy

PURPOSE

To report clinical characteristics of thyroid-associated ophthalmopathy (TAO) in patients who previously underwent total thyroidectomy for thyroid cancer or a benign mass of the thyroid.

MATERIALS AND METHODS

Of the patients who were diagnosed with TAO from March 2008 to March 2012, we performed a retrospective chart review on those who had undergone total thyroidectomy for thyroid cancer or a benign mass of the thyroid before the occurrence of ophthalmopathy.

RESULTS

Of the 206 patients diagnosed with TAO, seven (3.4%) met the inclusion criteria. The mean age of the subjects was 47.4 years, and all were female. Six patients were diagnosed with papillary thyroid cancer, and one was diagnosed with a benign mass. The duration between total thyroidectomy and onset of TAO ranged from 3-120 months (median 48 months). Ophthalmic manifestations varied among cases. Except for the patient who was diagnosed with a benign mass, all patients showed hyperthyroid status and were under Synthroid hormone treatment at the time of TAO development. Five of these six patients had positive levels of thyroid-stimulating hormone (TSH) receptor autoantibodies.

CONCLUSION

TAO rarely develops after total thyroidectomy, and the mechanism of TAO occurrence is unclear. However, most patients showed abnormalities in thyroid function and TSH receptor autoantibodies.

Autophagy is involved in the initiation and progression of Graves' orbitopathy

BACKGROUND

Differentiation of orbital fibroblasts into mature adipocytes and subsequent accumulation of adipose tissue has been shown in the progression of Graves' orbitopathy (GO). Autophagy is involved in adipogenesis, but little is known about the role of autophagy in the initiation and progression of GO. The aim of this study is to investigate the role of autophagy in the pathogenesis of GO.

METHODS

Orbital adipose/connective tissue explants from patients with GO and from normal subjects, as well as isolated orbital fibroblasts, were analyzed. Adipogenesis was induced using differentiating medium with or without hydrogen peroxide, and autophagy was manipulated using bafilomycin A1 and Atg5-targeted short hairpin RNA (shRNA). Autophagosomes were identified by electron microscopy. Expression of autophagy-related genes and adipogenesis-related transcription factors were analyzed by real time reverse transcription-polymerase chain reaction and/or Western blot analysis. Lipid droplet accumulation was examined by Oil Red O staining.

RESULTS

Autophagic vacuoles were more abundant in GO cells than in non-GO cells (p<0.05). Expression of autophagy-related genes was significantly higher in GO tissues and cells than in their non-GO counterparts, respectively. Interleukin-1β increased LC3-II, p62, and Atg7 protein in GO cells. Autophagosome accumulation was shown at day 4 of adipogenesis and decreased by day 10, along with lipid droplet formation. Expression of LC3 and p62 proteins increased within 48 hours of differentiation and diminished gradually from day 4 to 10. Bafilomycin A1 treatment and Atg5 knockdown by shRNA inhibited lipid droplet accumulation and suppressed expression of adipogenic markers.

CONCLUSIONS

Autophagy was increased in GO tissue and cells compared to non-GO tissue and cells, suggesting that autophagy plays a role in GO pathogenesis. Autophagy manipulation may be a therapeutic target for GO.

Genetic variations in the SOCS3 gene in patients with Graves' ophthalmopathy

AIMS

To explore the role of the suppressor of cytokine signalling 3 (SOCS3) gene in Graves' ophthalmopathy (GO) patients.

METHODS

A case-control study was conducted in a Chinese Han population by recruiting 114 Graves' disease (GD) patients with GO and 156 GD patients without GO. We determined SOCS3 mRNA and protein levels in Epstein-Barr virus-transformed lymphoblastoid cell lines (EBV-LCLs) from peripheral blood mononuclear cells (PBMCs) by quantitative real-time (QRT)-PCR analysis and western blot analysis. We also genotyped five single nucleotide polymorphisms (SNPs) in the SOCS3 locus (SOCS3 rs12952093, rs4969170, rs4969168, rs4969169 and rs2280148) in all 270 GD patients using ligase detection reaction and multiplex PCR analyses. QRT-PCR and western blot assays were then performed to compare SOCS3 mRNA and protein levels between the rs4969170 AA and GG genotype groups from 20 GO patients.

RESULTS

Basal SOCS3 mRNA and protein expression levels were significantly increased in patients with GO (p<0.05). The SOCS3 rs4969170 AA genotype was strongly associated with GO (OR=3.5, 95% CI 1.6 to 7.5, p=0.001). The AA genotype carriers had significantly higher SOCS3 mRNA and protein levels than those with the GG genotype (p<0.05).

CONCLUSIONS

Patients with GD who carry the AA genotype of the rs4969170 SNP in SOCS3 are more susceptible to the development of GO.

Salinomycin and other polyether ionophores are a new class of antiscarring agent

Although scarring is a component of wound healing, excessive scar formation is a debilitating condition that results in pain, loss of tissue function, and even death. Many tissues, including the lungs, heart, skin, and eyes, can develop excessive scar tissue as a result of tissue injury, chronic inflammation, or autoimmune disease. Unfortunately, there are few, if any, effective treatments to prevent excess scarring, and new treatment strategies are needed. Using HEK293FT cells stably transfected with a TGFβ-dependent luciferase reporter, we performed a small molecule screen to identify novel compounds with antiscarring activity. We discovered that the polyether ionophore salinomycin potently inhibited the formation of scar-forming myofibroblasts. Salinomycin (250 nm) blocked TGFβ-dependent expression of the cardinal myofibroblast products α smooth muscle actin, calponin, and collagen in primary human fibroblasts without causing cell death. Salinomycin blocked phosphorylation and activation of TAK1 and p38, two proteins fundamentally involved in signaling myofibroblast and scar formation. Expression of constitutively active mitogen activated kinase kinase 6, which activates p38 MAPK, attenuated the ability of salinomycin to block myofibroblast formation, demonstrating that salinomycin targets the p38 kinase pathway to disrupt TGFβ signaling. These data identify salinomycin and other polyether ionophores as novel potential antiscarring therapeutics.

Association of TLR7 and TSHR copy number variation with Graves' disease and Graves' ophthalmopathy in Chinese population in Taiwan

BACKGROUND

Graves' disease (GD) and Graves' ophthalmopathy (GO) are autoimmune disorders, which might be influenced by genetic factors. Copy number variation (CNV) is an important source of genomic diversity in humans, and influences disease susceptibility. This study investigated the association between CNV in the TSHR and TLR7 genes and the development of GD and GO in a Chinese population in Taiwan.

METHODS

For this case-control study, sample from 196 healthy controls and 484 GD patients, including 203 patients with GO were studied. CNV was detected by real-time polymerase chain reaction (PCR) using TaqMan™ probes and the relative copy number (CN) was estimated by using the comparative Ct method.

RESULTS

The differences in the distribution of TSHR CNV in healthy controls and GD patients were statistically significant (p value = 0.01). However, the difference in the distribution of TSHR CNV in the control group and the GO group was not statistically significant (p value = 0.06). For TLR7 CNV, the results were not significantly different when we compared the distribution in healthy controls and GD patients and in healthy controls and GO patients (p values for Fisher's exact test were 0.13 and 0.09, respectively). However, a lower than normal CNV for TLR7 (CNV < 2 for female and CNV < 1 for male) was found to have a protective effect against the development of GD (odds ratio (OR) = 0.24; 95% confidence interval (CI), 0.07-0.75) after adjusting for age and gender.

CONCLUSIONS

These results suggested that TSHR and TLR7 CNV might be associated with susceptibility to GD.

Orbital fibroblasts from thyroid eye disease patients differ in proliferative and adipogenic responses depending on disease subtype

PURPOSE

Thyroid eye disease (TED) patients are classified as type I (predominantly fat compartment enlargement) or type II (predominantly extraocular muscle enlargement) based on orbital imaging. Orbital fibroblasts (OFs) can be driven to proliferate or differentiate into adipocytes in vitro. We tested the hypothesis that type I OFs undergo more adipogenesis than type II OFs, whereas type II OFs proliferate more than type I OFs. We also examined the effect of cyclooxygenase (COX) inhibitors on OF adipogenesis and proliferation.

METHODS

Type I, type II, and non-TED OFs were treated with transforming growth factor-beta (TGFβ) to induce proliferation and with 15-deoxy-Δ(-12,14)-prostaglandin J2 (15d-PGJ2) to induce adipogenesis. Proliferation was measured using the [(3)H]thymidine assay, and adipogenesis was measured using the AdipoRed assay, Oil Red O staining, and flow cytometry. The effect of COX inhibition on adipogenesis and proliferation was also studied.

RESULTS

Type II OFs incorporated 1.7-fold more [(3)H]thymidine than type I OFs (P < 0.05). Type I OFs accumulated 4.8-fold more lipid than type II OFs (P < 0.05) and 12.6-fold more lipid than non-TED OFs (P < 0.05). Oil Red O staining and flow cytometry also demonstrated increased adipogenesis in type I OFs compared to type II and non-TED OFs. Cyclooxygenase inhibition significantly decreased proliferation and adipogenesis in type II OFs, but not type I OFs.

CONCLUSIONS

We have demonstrated that OFs from TED patients have heterogeneous responses to proproliferative and proadipogenic stimulators in vitro in a manner that corresponds to their different clinical manifestations. Furthermore, we demonstrated a differential effect of COX inhibitors on type I and type II OF proliferation and adipogenesis.

Comparison of optic disc topography in the cases with graves disease and healthy controls

PURPOSE

To compare the optic nerve head topographic parameters of the cases with Graves disease (GD), and the age and sex-matched control group, by using Heidelberg retinal tomography III.

MATERIALS AND METHODS

We evaluated both eyes of 65 patients with GD and 54 age and sex-matched controls. For statistical analysis, Mann-Whitney U test and independent sample t test were used. Statistical significance was set as P < 0.05.

RESULTS

The study group consisted of 22 male (33.8%) and 43 female (66.2%) GD cases with a mean age of 40.3 ± 11.9 years and the control group consisted of 26 male (48.1%) and 28 female (51.9%) healthy controls with a mean age of 36.9 ± 7.6 years. The differences between the age and sexes of the groups were not statistically significant (P = 0.07 and P = 0.11, respectively). The mean intraocular pressure of the study group was 14.6 ± 2.9 mm Hg (range, 8 to 20 mm Hg), whereas in the control group, it was 13.4 ± 2.1 mm Hg (range, 10 to 19 mm Hg). The difference between the intraocular pressures was statistically significant (P = 0.01). The mean retinal nerve fiber layer (RNFL) thickness (0.31 ± 0.08 mm) and the mean RNFL cross-sectional area (1.5 ± 0.43 mm) of the control group were greater than the mean RNFL thickness (0.25 ± 0.06 mm) and the mean RNFL cross-sectional area (1.30 ± 0.32 mm) of the study group (P = 0.02, P = 0.03 respectively).

CONCLUSIONS

This result suggests that patients with GD may have thinner RNFL than healthy controls.

Cigarette smoke extract-induced adipogenesis in Graves' orbital fibroblasts is inhibited by quercetin via reduction in oxidative stress

Cigarette smoking is known to aggravate Graves' orbitopathy (GO) severity by enhancing adipogenesis. We investigated the effect of quercetin, an antioxidant, on adipocyte differentiation induced by cigarette smoke extract (CSE) in primary cultured orbital fibroblasts (OFs) from GO patients. Freshly prepared CSE was added to the cells and H(2)O(2) was used as a positive control. Intracellular reactive oxygen species (ROS) generation and adipogenesis were measured. The expressions of proteins peroxisome proliferator-activated receptor (PPAR) γ, CCAAT-enhancer-binding proteins (C/EBP) α and β, and heme oxygenase-1 (HO-1), an antioxidant enzyme, were examined during adipogenic differentiation. In result, CSE and H(2)O(2) dose-dependently stimulated intracellular ROS production in normal and Graves' OFs. The effect of 2% CSE was similar to that of 10 μM H(2)O(2); both concentrations were noncytotoxic and were used throughout the experiment. Quercetin pretreatment reduced the ROS generation stimulated by either CSE or H(2)O(2) in preadipocyte OFs. CSE and H(2)O(2) stimulated adipocyte differentiation in cultured OFs. The addition of quercetin (50 or 100 μM) suppressed adipogenesis. Quercetin also suppressed ROS generation in differentiating OFs during adipogenesis stimulated by CSE and H(2)O(2). Additionally, the expressions of PPARγ, C/EBPα, and C/EBPβ proteins were reduced in the quercetin-treated OFs. Quercetin also reduced the CSE- and H(2)O(2)-induced upregulation of ROS and HO-1 protein in differentiated OFs and preadipocyte OFs. As shown in this study, quercetin inhibited adipogenesis by reducing ROS in vitro, supporting the use of quercetin in the treatment of GO.

Association of IL12B polymorphisms with susceptibility to Graves ophthalmopathy in a Taiwan Chinese population

Background

Interleukin 12B (IL12B) gene polymorphisms have been linked to several inflammatory diseases, but their role in the development of Graves ophthalmopathy (GO) in Graves disease (GD) patients is unclear. The purpose of this study was to investigate the disease association of IL12B single nucleotide polymorphisms (SNPs).

Methods

A Taiwan Chinese population comprising 200 GD patients with GO and 271 GD patients without GO was genotyped using an allele-specific extension and ligation method. Hardy-Weinberg equilibrium was estimated using the chi-square test. Allele and genotype frequencies were compared between GD patients with and without GO using the chi-square test.

Results

The genotype and allele frequencies of examined SNPs did not differ between GD patients with and without GO. Although the genotype distribution remained nonsignificant in the sex-stratified analyses, the frequency of the T allele at SNP rs1003199 was significantly higher in patients with GO in the male cohort (P = 6.00 × 10^-3). In addition, haplotypes of IL12B may be used to predict the risk of GO (P = 1.70 × 10^-2); however, we could not prove the statistical significance of analysis after applying the Bonferroni correction.

Conclusions

Our results provide new information that the examined IL12B gene polymorphisms may be associated with susceptibility to GO in the Taiwan Chinese population in a sex-specific manner. This conclusion requires further investigation.

The Immunology of Glaucoma

The presence of specific antibodies and T cells that are specific in patients with glaucoma supports the idea that the immune system may play an important role in the initiation and/or sustainment of glaucomatous optic neuropathy, at least in some patients. At present, our understanding regarding immunological mechanisms associated with glaucomatous optic neuropathy is far from satisfactory. In this review, we examined evidence suggesting involvement of autoimmune responses in the pathogenesis of glaucoma. These include detection of autoantibodies and T cells and expression of cytokines and stress proteins in patients with glaucoma. Although immune responses are thought to be detrimental, some responses may exert a protective effect against neurodegenerative damage. Likely, the balance between positive and negative regulators determines the survival or demise of cells. It is vital that research continues to elucidate the roles of the immune system in glaucomatous neurodegeneration and the possibility of alternative modalities of treatment. These studies may also provide valuable molecular biomarkers for the diagnosis and identification of a specific cohort of patients with glaucoma, that is, those with normal-tension glaucoma.

Ophthalmic changes in severe anorexia nervosa: a case series

OBJECTIVE

We describe the diagnosis and management of lagophthalmos, or failure of eyelid closure, in five patients with severe anorexia nervosa (AN) who complained of dry, irritated eyes and photophobia.

METHOD

Five patients with these findings are described retrospectively.

RESULTS

Examination revealed lagopthalmos in the setting of ptosis and enophthalmos, with multiple other starvation-mediated medical complications.

DISCUSSION

These eye findings, as complications of AN, have not been described in the literature. With careful protective measures, initiation of nutritional rehabilitation, and intensively monitored early refeeding, these patients' ocular abnormalities and associated symptoms resolved completely. Recognition of this pathology and appropriate management can prevent long-term morbidity in the form of permanent loss of visual acuity due to corneal abrasions and improve the outcomes for these patients with severe AN.

Quercetin inhibits IL-1β-induced inflammation, hyaluronan production and adipogenesis in orbital fibroblasts from Graves' orbitopathy

Management of Graves' orbitopathy (GO) is challenging, as no reliable, specific, and safe medical therapeutic agents have yet been developed. We investigated the effect of quercetin in primary cultured orbital fibroblasts from GO, targeting pathways of inflammation, aberrant accumulation of extracellular matrix macromolecules, and adipose tissue expansion. Quercetin significantly attenuated intercellular adhesion molecule-1 (ICAM-1), interleukin (IL) -6, IL-8, and cyclooxygenase (COX) -2 mRNA expression, and inhibited IL-1β-induced increases in ICAM-1, IL-6, and IL-8 mRNA. Increased hyaluronan production induced by IL-1β or tumor necrosis factor-α was suppressed by quercetin in a dose- and time-dependent manner. Treatment with noncytotoxic doses of quercetin inhibited accumulation of intracytoplasmic lipid droplets and resulted in a dose-dependent decrease in expression of peroxisome proliferator-activated receptor γ, CCAAT/enhancer-binding protein (C/EBP) α, and C/EBPβ proteins. In conclusion, inhibition of inflammation, hyaluronan production, and adipogenesis by the natural plant product quercetin in vitro provides the basis for further study of its potential use in the treatment of GO.

The association between polymorphisms of B7 molecules (CD80 and CD86) and Graves' ophthalmopathy in a Taiwanese population

OBJECTIVE

This study evaluates whether B7 molecules (CD80 and CD86) could be used as genetic markers for the development of Graves' ophthalmopathy (GO).

DESIGN

Cross-sectional study.

PARTICIPANTS

We included 471 patients with Graves' disease (GD; 200 patients with GO and 271 patients without GO) in a Chinese population in Taiwan.

METHODS

An endocrinologist with substantial experience in thyroid diseases identified GO. Blood samples were taken for DNA extraction from GD subjects. The gene polymorphism of CD80 and CD86 was genotyped by polymerase chain reaction in each patient.

MAIN OUTCOME MEASURES

Genotypes of CD80 and CD86 polymorphism.

RESULTS

We found that the frequency of C allele at position rs_9831894 of the CD86 gene is different in patients with GD (with and without GO; chi-square test, P = 0.0017). In addition, the multifactor dimensionality reduction method was used to identify the best gene-gene interaction to predict the risk of GO. We identified an interaction between CD80_rs9289131 and CD86_rs9872483 (sign test, P = 0.0010). Moreover, the G-A haplotype was shown to have a protective effect in the development of ophthalmopathy among patients with GD (odds ratio, 0.63; 95% confidence interval, 0.44-0.90). Moreover, among patients with GO, the patients carrying the G-A haplotype had a lower level of free thyroxine T(4) than those not carrying the G-A haplotype (P = 0.0001).

CONCLUSIONS

These results suggest that the polymorphisms of the CD86 gene may be used as genetic markers for making the diagnosis and prognosis of GO. Therefore, GO could be a disease with complex genetic factors, resulting from the existing gene-gene interaction found in the present study.

Graves' Ophthalmopathy Misdiagnosed as Relapsing Conjunctivitis

A 59-year-old female patient presented at the outpatients’ Department of Ophthalmology with epiphora, eyelid swelling, and a foreign body feeling in the right eye. The symptoms were present for 4 months, and the patient was treated as suffering from relapsing conjunctivitis. The slit lamp examination revealed keratitis due to exposure, related with the deficient closure of the eyelids. There was a 2 mm difference in the readings with the Hertel exophthalmometry examination between the eyes. Her medical history was clear, and she was referred for computed tomography of the orbits and brain and biochemical examinations (FT₃, FT₄, and TSH) to investigate the presence of an intraorbital mass. FT₃ was significantly increased and TSH was accordingly low, indicating the diagnosis of Graves’ disease, which presented without other signs and symptoms apart from ophthalmopathy. Computed tomography scan excluded the diagnosis of an intraorbital mass. Therefore, it is important not to underestimate the ocular manifestations of systemic diseases.

Disease association of the CD103 polymorphisms in Taiwan Chinese Graves' ophthalmopathy patients

OBJECTIVE

To evaluate whether variations in the CD103 gene could be associated with Graves' ophthalmopathy (GO) in patients with Graves' disease.

DESIGN

Case-control study.

PARTICIPANTS

A total of 484 Chinese patients with Graves' disease in Taiwan, including 203 patients with GO and 281 patients without GO, were enrolled.

METHODS

Five single nucleotide polymorphisms (SNPs) in CD103 were genotyped using an assay-on-demand allelic discrimination assay and detection system according to the manufacturer's instructions.

MAIN OUTCOME MEASURES

Association of SNPs in CD103 with the development of GO.

RESULTS

The CD103 SNP rs11652878 was associated with GO, which may decrease the risk of GO by 1.57-fold (P = 0.029). The Ht5-GCGCG haplotype, composed of 5 SNPs in the CD103 gene (rs1716, rs3744679, rs11652878, rs16953477, and rs9905739), were protective haplotypes (P = 0.010). Moreover, the heterozygous genotype (Ht5/non-Ht5) was correlated with a reduced risk of GO and high grades of goiter as compared with the non-Ht5/non-Ht5 genotype (P = 0.006 and P = 0.048, respectively). Logistic analysis confirmed the contribution of CD103 rs11652878 to the protection of GO.

CONCLUSIONS

These data suggest that patients with Graves' disease in the presence of the G allele of SNP rs11652878, especially Ht5-GCGCG, in CD103 are less susceptible toward the development of GO.

Mast cell-derived prostaglandin D2 controls hyaluronan synthesis in human orbital fibroblasts via DP1 activation: implications for thyroid eye disease

Thyroid eye disease (TED) is a debilitating disorder characterized by the accumulation of adipocytes and hyaluronan (HA). Production of HA by fibroblasts leads to remarkable increases in tissue volume and to the anterior displacement of the eyes. Prostaglandin D(2) (PGD(2)), mainly produced by mast cells, promotes orbital fibroblast adipogenesis. The mechanism by which PGD(2) influences orbital fibroblasts and their synthesis of HA is poorly understood. We report here that mast cell-derived PGD(2) is a key factor that promotes HA biosynthesis by orbital fibroblasts. Primary orbital fibroblasts from TED patients were isolated and used to test the effects of PGD(2), prostaglandin J(2), as well as prostaglandin D receptor (DP) agonists and antagonists on HA synthesis. The expression of HA synthase (HAS), hyaluronidase, DP1, and DP2 mRNA levels was assessed by PCR. Small interfering RNAs against HAS1 or HAS2 were used to assess the importance of HAS isoforms on HA production. Treatment of human orbital fibroblasts with PGD(2) and PGJ(2) increased HA synthesis and HAS mRNA. HAS2 was the dominant isoform responsible for HA production by PGD(2). The effect of PGD(2) on HA production was mimicked by the selective DP1 agonist BW245C. The DP1 antagonist MK-0524 completely blocked PGD(2)-induced HA synthesis. Human mast cells (HMC-1) produced PGD(2). Co-culture of HMC-1 cells with orbital fibroblasts induced HA production and inhibition of mast cell-derived PGD(2) prevented HA synthesis. Mast cell-derived PGD(2) increased HA production via activation of DP1. Selectively targeting the production of PGD(2) and/or activation of DP1 may prevent pathological changes associated with TED.

Update on the medical treatment of Graves' ophthalmopathy

PURPOSE

To review recent advances in the understanding of Graves' ophthalmopathy (GO) pathogenesis as well as discuss current and future medical management strategies.

DESIGN

Interpretive essay.

METHODS

Literature review and interpretation.

RESULTS

Medical treatment of GO has slowly evolved during the past few decades and has been hampered by a poor understanding of the disease at a cellular and molecular level. Current treatment recommendations and guidelines therefore focus on nonspecific immuno-suppression. Newer classes of treatment agents hold promise to more selectively target underlying cellular and molecular alterations in GO.

CONCLUSION

Cooperation between individual patients, physicians and between differing medical centers, together with a refined understanding of the pathogenesis of GO, will lead to newer more-effective treatments for the disease and improve patient quality of life.

Inferior oblique surgery for restrictive strabismus in patients with thyroid orbitopathy

INTRODUCTION

Thyroid orbitopathy is the most common cause of restrictive strabismus. Patients often present with vertical or horizontal double vision, or both, due to restriction involving most commonly the inferior and medial rectus muscles. Traditional muscle surgery involves release of the tight muscles. Previous literature has described a frequent need for secondary operations and an overcorrection incidence of up to 50%. Recognizing that the tight muscles are also limited in their excursion, it was proposed that operating on the better-moving eye, particularly the inferior oblique, might produce an improvement in binocularity and decrease the incidence of overcorrection.

METHODS

A total of 37 patients with restrictive strabismus due to thyroid orbitopathy treated at the University of Virginia over 12 years with inferior oblique surgery were retrospectively reviewed.

RESULTS

Eight patients were treated with a combination of inferior oblique surgery and horizontal muscle surgery at the same time. One patient was treated with simultaneous inferior oblique and superior rectus surgery. Seven patients had vertical correction with inferior oblique surgery alone. Twenty-three patients required secondary procedures. Eight patients were overcorrected but only one following primary surgery. At the time of last follow-up, ranging from 6 months to 8 years, 33 patients had no diplopia, 2 had minimal diplopia, and 2 had persistent diplopia. All but two were completely functional.

CONCLUSION

Inferior oblique surgery by balancing the overall excursion of extraocular muscles in thyroid patients may produce binocularity in primary position and down reading gaze. The amount of vertical correction from inferior oblique surgery alone is limited, often requiring ipsilateral superior or contralateral inferior rectus surgery. Inferior oblique surgery likely increases the area of binocular single vision and decreases the incidence of overcorrection. The use of Hess screen and binocular single vision fields is helpful in assessment and planning of surgery in these patients.

Thyroid eye disease

Introduction

Thyroid eye disease (TED), also known as Graves opthalmopathy is the most common orbital disease and affects 25–50% of patients with Graves' disease (Kuryan et al 2008). Most patients are only mildly affected, suffering ocular irritation with redness and watering, ‘staring eyes' due to retraction of the eyelids, exophthalmos (protrusion of the eyeballs) and periorbital swelling (Figure 1). A minority of patients (around 28%) will develop ocular motility problems, leading to diplopia (double vision), exposure/damage to the cornea and optic neuropathy (Kumar & Clarke 2002, Forbes & Jackson 2003, Meyer 2006).

Selected lid problems in neurologic practice

Ptosis is a common clinical finding. The many causes of ptosis include involutional (aging), myopathic, neuropathic, congenital, infectious, tumorous, traumatic, and inflammatory processes. This article reviews recent literature on some causes of ptosis and other lid conditions.