Medical treatment in thyroid eye disease in 2020

Effects of Teprotumumab and Role of Human Leukocyte Antigens Markers in Patients With Thyroid Eye Disease

OBJECTIVE

To evaluate the effects of teprotumumab on ophthalmologic and biochemical findings and assess potential genetic markers for response to treatment.

METHODS

This is a retrospective study. Participants were 18-76 year old. All subjects were treated with teprotumumab. The primary outcome was the change in proptosis before and after teprotumumab treatment. Secondary outcomes include change in other ophthalmic measures and thyroid laboratory tests. Human leukocyte antigens (HLA) markers were analyzed for response to teprotumumab.

RESULTS

Twenty-six patients were included in the final analysis. There was a significant decrease in thyroid stimulating immunoglobulin and thyrotropin receptor antibody levels and significant increases in glycated hemoglobin A1c, fasting glucose, and total T3 levels. There was also significant reduction in proptosis, clinical activity score, retinal nerve fiber layer thickness, ganglion cell analysis, and intraocular pressure. HLA haplotypes were distinct between responders and nonresponders, with HLA-DRB3 02:02:01G, HLA-DRB4 neg, and HLA-DQB1 02:01:01G demonstrating better response to teprotumumab and HLA-A 23:01:01G strongly correlating to nonresponse.

CONCLUSIONS

Patients with both acute and chronic thyroid eye disease treated with teprotumumab had a significant reduction in thyroid stimulating immunoglobulin and thyrotropin receptor antibody levels and improvement in proptosis, clinical activity score, retinal nerve fiber layer and ganglion cell analysis thickness, and intraocular pressure. HLA may predict responders vs nonresponders. Further studies with longer duration and larger population comparing teprotumumab with steroids or other immunomodulatory agents (tocilizumab, rituximab, etc) may be helpful.

Influence of orbital decompression on upper eyelid retraction in Graves' orbitopathy: a systematic review and meta-analysis

Graves'-associated upper eyelid retraction (GAUER) is the commonest manifestation of orbitopathy in adults. Surgical management typically follows a 3-step staged approach commencing with orbital decompression. The rationale behind this is that certain surgical interventions can influence the parameters and outcomes of subsequent procedures. We performed a systematic review and meta-analysis evaluating the effects of orbital decompression on GAUER in adult patients with Graves' orbitopathy. All original English, non-pediatric studies meeting the study inclusion criteria from the last 20 years were included. The characteristics of margin reflex distance 1 (MRD-1) pre- and post-orbital decompression of 688 orbits were collected, and a meta-analysis of 472 orbits was performed. The average reduction in MRD-1 across 688 orbits was found to be 0.40 mm. Meta-analysis of 6 applicable articles demonstrated that orbital decompression decreases MRD-1 by an average of 0.35 mm (n = 472, p = .007, 95% CI = [0.08, 0.63]). This study demonstrates that although statistically significant, orbital decompression does not appear to have a clinically significant effect on GAUER. This has implications for clinical practice, namely the likely requirement of eyelid surgery following or in combination with orbital decompression, and the importance of counselling patients on this preoperatively.

Orbital decompression following treatment with teprotumumab for thyroid eye disease

OBJECTIVE

To quantify the observed decrease in orbital decompressions being performed at one tertiary care institution and to determine the rate and predictive factors of orbital decompression surgery following treatment with teprotumumab for thyroid eye disease.

METHODS

Epic's SlicerDicer program was used to analyze recent trends in the overall number of thyroid eye disease (TED) patients evaluated in the oculoplastic surgery department, as well as usage trends of CPT codes 67445 (lateral orbitotomy with bone removal for decompression) and 67414 (orbitotomy with removal of bone for decompression). A retrospective chart review of active moderate-to-severe TED patients treated with teprotumumab was performed at a single tertiary care center. The main outcome measure was whether or not patients underwent bony orbital decompression surgery following treatment with teprotumumab. The SlicerDicer search demonstrated stable usage of CPT codes 67445 and 67414 from 2016 to 2019, followed by a significant decrease from 2020 to 2023, over a background of increasing numbers of TED patients evaluated in clinic. Following teprotumumab therapy, 25% of patients and 18% of orbits underwent bony decompression. Surgically decompressed patients had higher pre- and post-teprotumumab exophthalmometry measurements compared with patients who did not undergo bony decompression. Average time to decompression following conclusion or cessation of teprotumumab therapy was 12.6 months.

CONCLUSION

While the number of TED patients treated at one tertiary care center has risen over recent years, the number of orbital decompression surgeries has declined. Orbital decompression, however, is still needed in select patients after treatment with teprotumumab.

Efficiency and Safety of Tocilizumab for the Treatment of Thyroid Eye Disease: A Systematic Review

PURPOSE

To review existing literature concerning the effectiveness and safety of tocilizumab (TCZ) for managing thyroid eye disease.

METHODS

A systematic search was conducted across the PubMed and Embase databases to identify studies on TCZ therapy, from inception to May 2023. The search included the keywords "Graves orbitopathy," "thyroid ophthalmopathy," "thyroid eye disease," "thyroid-associated orbitopathy," "thyroid-associated ophthalmopathy," "Graves ophthalmopathy," "endocrine ophthalmopathy," and "Tocilizumab." Only articles written in English, Spanish, or French were considered.

RESULTS

Among the 1,013 articles initially screened, a total of 29 fulfilled the eligibility criteria and were selected. Most studies were case reports or case series, and only one randomized clinical trial was found. TCZ has been used mainly in glucocorticoid-resistant or relapsing cases, with a dosage ranging from 4 or 8 mg/kg every 4 weeks when intravenous or a weekly subcutaneous dose of 162 mg. Treatment duration is usually adjusted to the clinical response. TCZ is mostly effective in reducing inflammatory signs during the active phase of thyroid eye disease, with an improvement of at least 3 points in clinical activity score and an overall relapsing rate of 8.2%. Numerous studies have shown marked reductions in proptosis; although the only available randomized controlled trial reported a nonstatistically significant improvement 6 months after treatment, a recent meta-analysis indicated that TCZ seems to be the most effective treatment for reducing proptosis. No severe side effects related to intravenous or subcutaneous TCZ administration were reported.

DISCUSSION

Despite these promising findings, randomized clinical trials to directly compare the efficacy and safety of TCZ and other currently available therapeutic options are needed.

Purine metabolism-related genes and immunization in thyroid eye disease were validated using bioinformatics and machine learning

Thyroid eye disease (TED), an autoimmune inflammatory disorder affecting the orbit, exhibits a range of clinical manifestations. While the disease presentation can vary, cases that adhere to a prototypical pattern typically commence with mild symptoms that subsequently escalate in severity before entering a phase of stabilization. Notably, the metabolic activity of cells implicated in the disease substantially deviates from that of healthy cells, with purine metabolism representing a critical facet of cellular material metabolism by supplying components essential for DNA and RNA synthesis. Nevertheless, the precise involvement of Purine Metabolism Genes (PMGs) in the defensive mechanism against TED remains largely unexplored. The present study employed a bioinformatics approach to identify and validate potential PMGs associated with TED. A curated set of 65 candidate PMGs was utilized to uncover novel PMGs through a combination of differential expression analysis and a PMG dataset. Furthermore, GSEA and GSVA were employed to explore the biological functions and pathways associated with the newly identified PMGs. Subsequently, the Lasso regression and SVM-RFE algorithms were applied to identify hub genes and assess the diagnostic efficacy of the top 10 PMGs in distinguishing TED. Additionally, the relationship between hub PMGs and clinical characteristics was investigated. Finally, the expression levels of the identified ten PMGs were validated using the GSE58331 and GSE105149 datasets. This study revealed ten PMGs related with TED. PRPS2, PFAS, ATIC, NT5C1A, POLR2E, POLR2F, POLR3B, PDE3A, ADSS, and NTPCR are among the PMGs. The biological function investigation revealed their participation in processes such as RNA splicing, purine-containing chemical metabolism, and purine nucleotide metabolism. Furthermore, the diagnostic performance of the 10 PMGs in differentiating TED was encouraging. This study was effective in identifying ten PMGs linked to TED. These findings provide light on potential new biomarkers for TED and open up possibilities for tracking disease development.

The Efficacy and Safety of Teprotumumab in Thyroid Eye Disease: Evidence from Randomized Controlled Trials

In this study, we conducted a meta-analysis to assess the efficacy and safety of teprotumumab in treating thyroid eye disease. We searched the Cochrane Library, PubMed, and Embase databases from inception to May 25, 2022, and included all randomized controlled trials. Odds ratios (ORs) were calculated using fixed- or random-effect models. A total of three studies involving 341 patients were identified. Overall, the analysis revealed that teprotumumab demonstrated superior integrated proptosis response compared to placebo in both the intention-to-treat (ITT) population (OR = 17.81, 95% CI = [10.32, 30.76], I2 = 50%) and per-protocol population (OR = 24.53, 95% CI = [12.96, 46.45], I2 = 14%). Furthermore, patients receiving teprotumumab showed significant improvement in overall response (OR = 8.35, 95% CI = [4.74, 14.71], I2 = 79%), diplopia response (OR = 5.53, 95% CI = [3.24, 9.44], I2 = 0%), and achieving a clinical activity score (CAS) of 0 or 1 (OR = 6.26, 95% CI = [3.87, 10.12], I2 = 0%). Moreover, patients treated with teprotumumab experienced greater improvements in proptosis (MD = -2.49, 95% CI = [-2.54, -2.45], I2 = 98%) and Graves' ophthalmopathy-specific quality of life (GO-QOL, MD = 11.48, 95% CI = [11.03, 11.93], I2 = 95%). However, it is important to note that patients receiving teprotumumab had a higher risk of adverse events, including serious adverse events, gastrointestinal adverse reactions, and muscle spasms. In summary, teprotumumab demonstrated greater improvement in proptosis response, proptosis, diplopia response, overall response, GO-QOL, and CAS. Nonetheless, it should be considered that its use is associated with a higher risk of adverse events.

Teprotumumab-trbw as a Novel Monoclonal Antibody for Thyroid Eye Disease: A Literature Review

Thyroid eye disease (TED) can cause disfigurement and vision loss, most commonly in patients with Graves' disease. These symptoms are related to orbital inflammation subsequently cause proptosis and limited eye movement. Traditionally, TED is treated with corticosteroids to decrease inflammation and surgery once the disease stabilizes. However, multiple medications that play a role in immune modulation have been tested and found to be beneficial in treating TED, either as an adjuvant to steroids or in severe disease resistant to steroids. Teprotumumab-trbw, a novel monoclonal antibody sold under the trade name Tepezza®, is the first immune modulator to be approved by the Unites States Food and Drug Administration (FDA) for TED. Teprotumumab-trbw targets the insulin-like growth factor-1 receptor, which is upregulated on orbital fibroblasts and decreases activation in patients with TED. The FDA approved this drug for patients with less than nine months of disease duration and high levels of disease activity. Multiple studies have shown significant positive results in disease modulation, as well as limited side effects.

[Graves' orbitopathy: Current concepts for medical treatment]

BACKGROUND

The therapy of severe manifestations of Graves' orbitopathy (GO) is still a challenge and requires good interdisciplinary cooperation. It is especially important to use stage-adapted anti-inflammatory therapy to avoid irreversible damage.

MATERIAL AND METHODS

Discussion of the latest results of multicentre randomised therapy studies on anti-inflammatory treatments for Graves' orbitopathy, as well as new therapeutic concepts.

RESULTS

Mild cases of GO can be treated with only selenium supplementation and a watchful waiting strategy. In the moderate-to-severe active form of GO, primary therapy consists of i. v. steroids (cumulative 4-5 g) in combination with orbital irradiation in patients with impaired motility. In patients with insufficient therapeutic response after 6 weeks, treatment should be switched to other immunosuppressive agents. In severe sight-threatening disease, bony orbital decompression is usually necessary. As basic research has improved our understanding of the underlying pathophysiology of GO, it has been possible to develop targeted therapies for GO. Teprotumumab, an IGF-1 receptor antibody, was effective in treating GO patients in a phase III trial and should soon be awarded approval for Europe.

CONCLUSION

The current therapy concept for Graves' orbitopathy is as follows: first anti-inflammatory therapy then surgical correction of the permanent defects. This may soon be modified, due to the use of targeted therapies.

Outcome of tocilizumab treatment in corticosteroid-resistant thyroid eye disease

INTRODUCTION

Thyroid eye disease (TED) is a complex and incompletely understood rare autoimmune disorder.

OBJECTIVES

To analyze the experience and the outcomes obtained with the use of intravenous tocilizumab in the treatment of TED.

METHODS

A retrospective analysis of adult patients diagnosed with active TED resistant to intravenous corticosteroids treated in a tertiary hospital between May 2012 and May 2021.

RESULTS

Eleven patients were included with a mean age of 52±12 (range 35-67) years. Nine patients were female and two were male. Patients received a median of 5±3.2 doses. Twenty out of twenty-four eyes achieved inactivation of TED at week 16. Proptosis response was achieved in 6/8 patients and diplopia response in 3/8 patients. The GO-QOL questionnaire showed clinically significant improvement in 9/11 patients. No serious adverse effects were reported during tocilizumab treatment. One patient required decompressive surgery 15 months after tocilizumab therapy.

CONCLUSION

The results obtained show that the use of tocilizumab in the treatment of this pathology can be a good alternative.

Ocular surface and in vivo confocal microscopic findings in patients with active tyhroid eye disease treated with glucocorticoids

OBJECTIVES

To evaluate the effect of treatment with high-dose glucocorticoids (HDG) on ocular surface parameters and in vivo confocal microscopy (IVCM) findings in patients with active thyroid eye disease (TED).

METHODS

This study included 15 active TED patients treated with a cumulative HDG dose of 4.5g (500 mg and then 250 mg for 6 weeks each). Disease activity was assessed by the clinical activity score (CAS), Graves' Orbitopathy-specific Quality of Life (GO-QoL) questionnaire, ocular surface disease index (OSDI), tear break-up time(T-BUT), ocular surface staining and IVCM.

RESULTS

The mean follow-up time was 48.6 months. The treatment resulted in a significant improvement in the T-BUT, ocular surface staining values. In comparison to the baseline, a notable reduction in CAS, OSDI and an increase in GO-QoL were seen after one year. IVCM showed a significant decrease in the number of dendritic cells, activated keratocytes, the degree of tortuosity, there was also a significant increase in the number of basal epithelial cells and total nerves over one-year period. All of those changes remained stable during the follow-up period.

CONCLUSION

HDG treatment results in a sustained decrease in corneal inflammatory cells, an increase in tear film stability, and an improvement in disease symptoms and QoL scores for up to 4 years.

Endoscope-navigation-assisted orbital decompression for graves' orbitopathy

PURPOSE

To compare the surgical outcomes of endoscope-navigation (EN)-assisted orbital decompression and non-EN-assisted orbital decompression for Graves' orbitopathy (GO) and to assess the potential clinical advantage of EN in orbital decompression surgery.

METHODS

This retrospective cohort study was performed on 227 orbits of 147 GO patients who underwent EN-assisted orbital decompression (185 orbits) or non-EN-assisted orbital decompression (42 orbits). Assessment included proptosis reduction, best-corrected visual acuity (BCVA), diplopia, ocular restriction and surgical complications.

RESULTS

The proptosis reduction in the EN group was 0.9 mm greater than that in the non-EN group in the entire cohort (p  =  0.004) and 1.0 mm greater than that in the non-EN group in the propensity score matching cohort (p  =  0.025) at 2 years postoperatively. In all, 78.2% of orbits with sight-threatening GO in the EN group and 52.6% of orbits in the non-EN group showed BCVA improvement (p  =  0.026). The proportion of patients with improvement in diplopia was significantly greater in the EN group than in the non-EN group (p  =  0.026).

CONCLUSIONS

EN offers anatomical localization and deep-seated tissue visualization in orbital decompression and significantly improves the surgical outcomes for GO.

Thyroid Eye Disease

Thyroid eye disease (TED), an autoimmune inflammatory disorder of the orbit, presents with a potential array of clinical sequelae. The pathophysiology behind TED has been partially characterized in the literature. There remain certain elusive mechanisms welcoming of research advances. Disease presentation can vary, but those that follow a characteristic course start mild and increase in severity before plateauing into an inactive phase. Diagnosis and evaluation include careful physical examination, targeted laboratory work up, appropriate imaging studies, and tailored treatment regimens. Special consideration may apply to certain populations, such as pediatric and pregnant patients.

Construction of the coexpression network involved in the pathogenesis of thyroid eye disease via bioinformatics analysis

Background

Thyroid eye disease (TED) is the most common orbital pathology that occurs in up to 50% of patients with Graves’ disease. Herein, we aimed at discovering the possible hub genes and pathways involved in TED based on bioinformatical approaches.

Results

The GSE105149 and GSE58331 datasets were downloaded from the Gene Expression Omnibus (GEO) database and merged for identifying TED-associated modules by weighted gene coexpression network analysis (WGCNA) and local maximal quasi-clique merger (lmQCM) analysis. EdgeR was run to screen differentially expressed genes (DEGs). Transcription factor (TF), microRNA (miR) and drug prediction analyses were performed using ToppGene suite. Function enrichment analysis was used to investigate the biological function of genes. Protein–protein interaction (PPI) analysis was performed based on the intersection between the list of genes obtained by WGCNA, lmQCM and DEGs, and hub genes were identified using the MCODE plugin. Based on the overlap of 497 genes retrieved from the different approaches, a robust TED coexpression network was constructed and 11 genes (ATP6V1A, PTGES3, PSMD12, PSMA4, METAP2, DNAJA1, PSMA1, UBQLN1, CCT2, VBP1 and NAA50) were identified as hub genes. Key TFs regulating genes in the TED-associated coexpression network, including NFRKB, ZNF711, ZNF407 and MORC2, and miRs including hsa-miR-144, hsa-miR-3662, hsa-miR-12136 and hsa-miR-3646, were identified. Genes in the coexpression network were enriched in the biological processes including proteasomal protein catabolic process and proteasome-mediated ubiquitin-dependent protein catabolic process and the pathways of endocytosis and ubiquitin-mediated proteolysis. Drugs perturbing genes in the coexpression network were also predicted and included enzyme inhibitors, chlorodiphenyl and finasteride.

Conclusions

For the first time, TED-associated coexpression network was constructed and key genes and their functions, as well as TFs, miRs and drugs, were predicted. The results of the present work may be relevant in the treatment and diagnosis of TED and may boost molecular studies regarding TED.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40246-022-00412-0.

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.

Tocilizumab for the Management of Thyroid-Associated Orbitopathy

PURPOSE

To describe the efficacy of tocilizumab in the treatment of a cohort of patients with active thyroid-associated orbitopathy.

METHODS

Patients were identified with active thyroid-associated orbitopathy who were intolerant of or had progression of disease despite systemic corticosteroids and subsequently were treated with tocilizumab between January 2015 and December 2020. Clinical Activity Score, Thyroid-Associated Ophthalmopathy Scale score, and thyroid-stimulating immunoglobulin levels were assessed prior to initiation of tocilizumab, following the first dose, and after the completion of treatment.

RESULTS

Eleven patients were candidates for and underwent treatment with tocilizumab, 9 of which met criteria for analysis. Average age was 55.6 years. Average time between onset of active thyroid-associated orbitopathy and completion of tocilizumab was 6.5 months. Average number of infusions was 4.2. There was a statistically significant reduction in Clinical Activity Score, Thyroid-Associated Ophthalmopathy Scale score, and thyroid-stimulating immunoglobulin levels when comparing pre-treatment values (mean Clinical Activity Score 6.78 ± 1.09, mean Thyroid-Associated Ophthalmopathy Scale score 10.2 ± 1.92, mean thyroid-stimulating immunoglobulin level 440.6 [%]) to values immediately following completion of treatment (mean Clinical Activity Score 0.44 ± 0.53, mean difference 6.3 points, p < 0.001 [95% CI, 5.5-7.2]; mean Thyroid-Associated Ophthalmopathy Scale score 1.2 ± 1.09, mean difference 9.0 points, p < 0.001 [95% CI, 7.2-10.8]; mean thyroid-stimulating immunoglobulin level 200.7 [%], mean difference 239.9 [%], p = 0.001 [95% CI, 124.3-355.4]). One patient had elevation of cholesterol following therapy induction. Patients were followed for an average of 23.6 months after treatment. No patients had recurrence of active disease after completion of tocilizumab.

CONCLUSIONS

This study supports the use of tocilizumab as a therapy for the inflammatory phase of thyroid-associated orbitopathy.

Intravenous rituximab therapy for active Graves' ophthalmopathy: a meta-analysis

AIM

The successful treatment of Graves' ophthalmopathy (GO) remains a challenge, while the efficacy of rituximab (RTX) is at present controversial. The aim of this meta-analysis was to investigate the potential impact of intravenous RTX therapy in patients with GO.

METHODS

We performed a search in the PubMed, Embase, and Web of Science databases for relevant studies published before July 2020. The primary outcome was the change of clinical activity score (CAS), and secondary outcomes were the change of proptosis and TSH receptor antibodies (TRAb). A meta-analysis was conducted to calculate the standard mean difference (SMD) for these outcomes by using fixed- or random-effect models.

RESULTS

Analysis of outcomes in 152 patients collected from 12 published articles was conducted. Compared to baseline value, CAS was significantly decreased at 1, 6, 12, and >12 months after RTX treatment. For proptosis, the results revealed no significant decrease at 1-3, 6, and ≥12 months. Moreover, the pooled analysis employed in this meta-analysis showed no significant difference of TRAb at 1 month, but significant declines were observed at 6 and ≥12 months.

CONCLUSION

Our results strongly suggest that intravenous RTX treatment has an acute and long-lasting beneficial effect on decreasing both CAS and TRAb. The study also indicates that the effect of RTX on proptosis is limited. There is evidently a need to investigate the mechanism behind RTX ineffectiveness on proptosis and explore other therapeutic regimens for the reduction of proptosis.

Graves' Orbitopathy: Current Concepts for Medical Treatment

BACKGROUND

The therapy of severe manifestations of Graves' orbitopathy (GO) is still a challenge and requires good interdisciplinary cooperation. It is especially important to use stage-adapted anti-inflammatory therapy to avoid irreversible damage.

MATERIAL AND METHODS

Discussion of the latest results of multicentre randomised therapy studies on anti-inflammatory treatments for Graves' orbitopathy, as well as new therapeutic concepts.

RESULTS

Mild cases of GO can be treated with only selenium supplementation and a watchful waiting strategy. In the moderate-to-severe active form of GO, primary therapy consists of i. v. steroids (cumulative 4 - 5 g) in combination with orbital irradiation in patients with impaired motility. In patients with insufficient therapeutic response after 6 weeks, treatment should be switched to other immunosuppressive agents. In severe sight-threatening disease, bony orbital decompression is usually necessary. As basic research has improved our understanding of the underlying pathophysiology of GO, it has been possible to develop targeted therapies for GO. Teprotumumab, an IGF-1 receptor antibody, was effective in treating GO patients in a phase III trial and should soon be awarded approval for Europe.

CONCLUSION

The current therapy concept for Graves' orbitopathy is as follows: first anti-inflammatory therapy then surgical correction of the permanent defects. This may soon be modified, due to the use of targeted therapies.

Updates on the understanding and management of thyroid eye disease

Thyroid eye disease (TED) is a complex disease associated with myriad clinical presentations, including facial disfigurement, vision loss, and decreased quality of life. Traditionally, steroid therapy and/or radiation therapy were commonly used in the treatment of active TED. While these therapies can help reduce inflammation, they often do not have a sustainable, significant long-term effect on disease outcomes, including proptosis and diplopia. Recent advances in our understanding of the pathophysiology of TED have shifted the focus of treatment toward targeted biologic therapies. Biologics have the advantage of precise immune modulation, which can have better safety profiles and greater efficacy compared to traditional approaches. For instance, the insulin-like growth factor-1 receptor (IGF-1R) has been found to be upregulated in TED patients and to colocalize with the thyroid-stimulating hormone receptor (TSHR), forming a signaling complex. Teprotumumab is an antibody targeted against IGF-1R. By inhibiting the IGF-1R/TSHR signaling pathway, teprotumumab may reduce the production of proinflammatory cytokines, hyaluronan secretion, and orbital fibroblast activation in patients with TED. Due to promising phase II and III clinical trial results, teprotumumab has become the first biologic US Food and Drug Administration (FDA)-approved for the treatment of TED. In addition, there are currently ongoing studies looking at the use of antibodies targeting the neonatal Fc receptor (FcRn) in various autoimmune diseases, including TED. FcRn functions to transport immunoglobulin G (IgG) and prevent their lysosomal degradation. By blocking the recycling of IgG, this approach may dampen the body's immune response, in particular the pathogenic IgG implicated in some autoimmune diseases. Advances in our understanding of the pathophysiology of TED, therefore, are leading to more targeted therapeutic options, and we are entering an exciting new phase in the management of TED. This review will cover recent insights into the understanding of TED pathophysiology and novel treatment options as well as ongoing studies of new potential treatment options for TED.

Strategies in Surgical Decompression for Thyroid Eye Disease

Surgical management of thyroid eye disease- (TED-) associated morbidity has been plagued by the complex interplay of different operative techniques. Orbital decompression is the well-recognized procedure for disfiguring exophthalmos and dysthyroid optic neuropathy (DON). There are numerous published techniques described for the removal of the orbital bone, fat, or a combination. The diverse studies are noncomparative as they include different indications, stages of disease, and methods of evaluation. Thus, it is difficult to conclude the most efficient decompression technique. To obtain effective and predictable results, it is therefore important to propose a logical and acceptable clinical guideline to customize patient treatment. Herein, we developed an algorithm based on the presence of DON, preoperative existing diplopia, and severity of proptosis which were defined by patient's disabling symptoms together with a set of ocular signs reflecting visual function or cosmesis. More specifically, we aimed to assess the minimal but effective surgical technique with acceptable potential complications to achieve therapeutic efficacy. Transcaruncular or inferomedial decompressions are indicated in restoring optic nerve function in patients with DON associated with mild or moderate to severe proptosis, respectively. Inferomedial or fatty decompressions are effective to treat patients with existing diplopia associated with mild or moderate to severe proptosis, respectively. Fatty or balanced decompressions can improve disfiguring exophthalmos in patients without existing diplopia associated with mild to moderate or severe proptosis, respectively. Inferomedial or 3-wall decompressions are preferred to address facial rehabilitation in patients associated with very severe proptosis but without preoperative diplopia.