Classification of the eye changes of Grave's disease

Assessment of serum dipeptidyl peptidase-IV levels in autoimmune thyroid disease

OBJECTIVE

Decreased serum dipeptidyl peptidase-IV (sDPPIV) levels have been reported in patients with autoimmune diseases. However, few studies have analyzed the association between sDPPIV levels and autoimmune thyroid disease (AITD). This study aimed to evaluate the association between sDPPIV levels and three types of AITD: Graves' disease (GD), Graves' ophthalmopathy (GO), and Hashimoto's thyroiditis (HT).

METHODS

Patients newly diagnosed with GD (n = 65), GO (n = 22), and HT (n = 27) and healthy individuals (n = 30) were recruited. Clinical characteristics and thyroid function data were collected. sDPPIV was measured using enzyme-linked immunosorbent assays.

RESULTS

Compared with controls (786.3 ± 46.95), patients with GD and GO had significantly lower sDPPIV levels (662.2 ± 38.81 and 438.4 ± 31.78). Additionally, sDPPIV levels were negatively associated with antithyroid peroxidase antibody (r = -0.20) and antithyroglobulin antibody (r = -0.19), but there was no significant relationship between thyroid hormone and sDPPIV levels. GO cases were divided by proptosis with and without muscle thickening; sDPPIV levels were lower in the muscle thickening group than those in the without muscle thickening group. Logistic regression analysis showed that sDPPIV was negatively correlated with GO and GD.

CONCLUSIONS

sDPPIV concentrations were abnormal in patients with GD and GO, and reduced sDPPIV expression may be involved in the progression of GO and GD.

American Thyroid Association Guidelines and Statements: Past, Present, and Future

BACKGROUND

The American Thyroid Association (ATA) is continually striving to improve the quality of its publications. The ATA Guidelines Policies and Procedures Task Force was active during 2017. It recently recommended convening a formal standing committee to review and update policies and procedures for the development of clinical practice guidelines (CPGs) and Statements on an ongoing basis.

OBJECTIVE

This statement reviews the history of official ATA publications and discusses the challenges and findings identified by the Task Force. We also wish to present our "work in progress" and propose future directions for the new ATA Guidelines and Statements Committee (ATA GSC).

METHODS

Our Task Force reviewed the publication record of the ATA with respect to CPGs. We also reviewed existing ATA policies for CPGs and other official statements, examined policies of other organizations, solicited input from external experts and organizations, and convened five conference calls and two in-person meetings.

RESULTS

The ATA has a rich history of developing official publications that have been influential based on download and citation records as well as changes in practice trends. Key future issues to be further addressed by the ATA GSC include the following: (i) striving to improve the methodologic rigor of development of CPGs while balancing considerations of feasibility and timeliness and the role of transparently communicated expert opinion; (ii) formalizing a framework and process for development of new Statements; (iii) increasing stringency and transparency of management of competing interests of individuals being considered for CPG/Statement panel membership; (iv) encouraging consideration of equity and diversity in CPG/Statement development group composition; (v) increasing relevant stakeholder representation (including patient representatives) in development of CPGs/Statements; and (vi) expanding future guideline implementation strategies.

CONCLUSIONS

As shown by the completed literature search, the ATA has a long history of producing CPGs and Statements with global impact on informing clinical management, education, and research in thyroid diseases. The ATA remains committed to a process of continual improvement of its publications and to meeting stakeholder information needs. Based on the work of our Task Force, we have identified many elements that are needed to achieve this goal and areas of challenge for our new committee.

Sagittal Magnetic Resonance Imaging of Dysthyroid Ophthalmopathy

Sagittal magnetic resonance imaging (MRI) scans of the eye and orbit were made of 30 eyes in 15 cases of dysthyroid ophthalmopathy (DO). On the basis of these scans, we sought to elucidate relationships between the morphological condition of the levator palpebrae muscle, fatty tissue in the upper eyelid and the superior, inferior recti muscles and the occurrence of such symptoms as lid retraction, lid swelling and vertical disturbance of eye movement. The levator palpebrae muscle was enlarged in all 15 DO eyes (100%) with upper eyelid retraction. In 16 (88.9%) of 18 eyes with apparent lid swelling, enlargement of the preaponeurotic fat or submuscular fat pad was clearly evident. In the control eyes, no such enlargement was seen in either the levator palpebrae muscle or orbital fatty tissue. The clear space between the superior recti and the levator palpebrae muscles that was seen in control eyes was absent in all five eyes that presented a disturbance in infraduction. In 8 (80%) of 10 eyes with a disturbance in supraduction, the inferior rectus muscle was enlarged and muscle extension was impaired. Sagittal MRI seemed to be a useful means of obtaining a better clinical understanding of a variety of eye symptoms associated with DO.

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.

A review on ocular findings in mouse lemurs: potential links to age and genetic background

Mouse lemurs, the world's smallest primates, inhabit forests in Madagascar. They are nocturnal, arboreal and dependent on vision for their everyday lives. In the last decades, the grey mouse lemur became increasingly important for biomedical research, in particular aging research. Experiments which require the combination of visual fitness and old age consequently depend on a solid knowledge of ocular pathologies. Although ocular diseases in mouse lemurs have been described as being common, they have not received much attention so far. Yet it is important to know when and why ocular diseases in captive mouse lemurs may occur. This review aims to provide a comprehensive overview of known ocular findings in mouse lemurs. It summarizes the frequency of ocular findings in captive mouse lemur colonies and points to their likely causes and treatment options based on the evidence available from other animals and humans. In addition, it shall be discussed whether age or genetic background may affect their development. This review may be used as a reference for future studies which require an assessment of visual performance in mouse lemurs and help to evaluate observed clinical signs and ocular diseases. Furthermore, the high incidence of specific diseases may provide new perspectives and set the groundwork for a new animal model for ocular research.

Distinct inflammatory gene expression in extraocular muscle and fat from patients with Graves' orbitopathy

OBJECTIVE

This study sought to compare patients with thyroid eye disease (TED) and normal controls with respect to the expression of the NR3C1, CHUK, IKBKB, FOS, NFKB and HSD11B1 genes in orbital fat (OF) and extraocular muscle (EOM).

DESIGN AND METHODS

A prospective study design was used to evaluate 34 TED patients and 38 healthy controls. OF was harvested from 33 TED patients and 27 controls. EOM biopsies were obtained from 32 TED patients and 18 controls. Samples were examined by real-time PCR and evaluated using appropriate statistical analyses with a significance cut-off of P < 0.05.

RESULTS

NR3C1 mRNA levels were higher in TED EOM (median 213 (96-376)) than those in control EOM (78 (34-138)) (P < 0.001), and NFKB expression was elevated in TED muscle (223 (31-520)) relative to that in control muscle (8 (6-31)) (P < 0.001). HSD11B1 expression was higher in TED EOM (0.78 (0.47-2.01)) than that in control EOM (0.22 (0.09-0.51)) (P < 0.001). Levels of CHUK, IKBKB, and FOS were higher in TED EOM (115 (20-223), 111 (54-299) and 0.11 (0.03-0.19), respectively) than those in control EOM (5.8 (2-13), 21 (5-52) and 0.05 (0.001-0.03) respectively) (P < 0.001).

CONCLUSION

Tissues involved in GO exhibited different mRNA levels of NR3C1, CHUK, IKBKB, FOS, NFKB and HSD11B1. Gene expression in OF was similar for TED patients and controls. CHUK, IKBKB, FOS, NFKB, and HSD11B1 mRNA levels were higher in TED EOM than those in control EOM. NFKB was disproportionally elevated compared with NR3C1; this finding was indicative of a local proinflammatory profile.

Thyroid-associated Ophthalmopathy

Thyroid-associated ophthalmopathy is the most frequent extrathyroidal involvement of Graves’ disease but it sometimes occurs in euthyroid or hypothyroid patients. Thyroid-associated ophthalmopathy is an autoimmune disorder, but its pathogenesis is not completely understood. Autoimmunity against putative antigens shared by the thyroid and the orbit plays a role in the pathogenesis of disease. There is an increased volume of extraocular muscles, orbital connective and adipose tissues. Clinical findings of thyroid-associated ophthalmopathy are soft tissue involvement, eyelid retraction, proptosis, compressive optic neuropathy, and restrictive myopathy. To assess the activity of the ophthalmopathy and response to treatment, clinical activity score, which includes manifestations reflecting inflammatory changes, can be used. Supportive approaches can control symptoms and signs in mild cases. In severe active disease, systemic steroid and/or orbital radiotherapy are the main treatments. In inactive disease with proptosis, orbital decompression can be preferred. Miscellaneous treatments such as immunosuppressive drugs, somatostatin analogs, plasmapheresis, intravenous immunoglobulins and anticytokine therapies have been used in patients who are resistant to conventional treatments. Rehabilitative surgeries are often needed after treatment.

Natural course of mild Graves' orbitopathy: is it a chronic remitting or a transient disease?

BACKGROUND/AIMS

The natural course of Graves' orbitopathy (GO) has been poorly documented. The aim of this review is to provide current knowledge regarding the natural course of mild GO, trying to address the issue of whether and to what extent it constitutes a chronic remitting or transient disease.

METHODS

We systematically searched PubMed for English language publications until August 2016 under the following terms: "Graves' orbitopathy" OR "Graves' ophthalmopathy" OR "thyroid eye disease" AND "natural course" OR "natural history".

RESULTS

Few studies have investigated the course of mild orbital disease in patients with GO. Large controlled trials are lacking and data can be extracted mainly from small retrospective and some prospective studies, after excluding patients who had received radioiodine for thyrotoxicosis or surgical treatment for GO. In general, more than half of GO patients may show spontaneous improvement in their clinical features, whereas no safe conclusions can be drawn with regard to complete resolution, with percentages ranging from 6 to 58 %.

CONCLUSIONS

The question whether mild GO is a remitting, albeit chronic disease, or even a transient event in the course of Graves' disease, remains currently unanswered.

Double vision is a major manifestation in moderate to severe graves' orbitopathy, but it correlates negatively with inflammatory signs and proptosis

CONTEXT

Double vision (diplopia) is a major determinant of work disability in patients with Graves' orbitopathy (GO), but is not part of the classification NOSPECS classification of GO.

OBJECTIVE

The objectives of the study were to quantitate diplopia in patients with moderate to severe GO and to study associations with other disease and patient variables.

DESIGN

This was a single-center prospective study of consecutive patients at the time of referral.

SETTING

The study was conducted at the University Hospital Thyroid-Eye Clinic.

PATIENTS

Patients included 216 patients diagnosed with moderate to severe and active GO.

MAIN OUTCOME MEASURES

Binocular diplopia in field of gaze and monocular fields of motility were prospectively recorded on diagrams and measured by planimetry. Fields of diplopia were correlated to other disease and patient variables.

RESULTS

Six patients had only one functional eye and were excluded. Among the remaining 210 patients, diplopia was present in 75.2%. In patients with diplopia, this ranged from 5% to 100% (observed in 11.4% of patients) of binocular field of gaze. The field of diplopia correlated positively with eye motility restriction and with asymmetrical affection of orbits but negatively with signs of inflammation and proptosis that often are the main outcome measures in clinical studies of GO therapy.

CONCLUSION

Diplopia is very common in moderate to severe GO and a major cause for active therapy. In moderate to severe GO, the field of diplopia correlates negatively with some other indicators of disease activity, which may be explained by the physiological properties of binocular fusion.

Excessive iodine intake does not increase the recurrence rate of graves' disease after withdrawal of the antithyroid drug in an iodine-replete area

BACKGROUND AND OBJECTIVES

The relationship between iodine intake and effects of antithyroid drugs (ATD) for Graves' disease, especially in iodine-deficient areas, has been demonstrated in many studies. However, it was not clear how chronic high iodine intake influenced the effectiveness of ATD in an iodine-replete area. This study aimed to clarify the effect of iodine intake on clinical outcomes of Graves' disease after discontinuation of ATD in Korea, an iodine-replete area.

METHODS

A total of 142 patients with Graves' disease who visited the outpatient clinic regularly and stopped their ATD between October 2011 and April 2013 were enrolled in our study. Urinary iodine concentration (UIC) was measured just before and after the discontinuation of ATD.

RESULTS

Median UIC was not significantly different between the remission and relapse groups, as well as among the four treatment groups (group 1, remission after initial treatment; group 2, remission after repeated treatment; group 3, early relapse within a year; group 4, late relapse after a year). Remission rates did not show a significant difference between the excessive iodine intake (UIC ≥300 μg/l) and average iodine intake groups (UIC <300 μg/l).

CONCLUSIONS

The present study suggests that excessive iodine intake does not have an effect on the clinical outcomes of Graves' disease in an iodine-replete area, and therefore diet control with iodine restriction might not be necessary in the management of Graves' disease.

Efficacy of B-cell targeted therapy with rituximab in patients with active moderate to severe Graves' orbitopathy: a randomized controlled study

BACKGROUND

Preliminary studies have shown that rituximab (RTX) is effective in the treatment of active Graves' orbitopathy (GO).

METHODS

We conducted a double-blind, randomized trial (European Clinical Trials Database [EudraCT] 2007-003910-33) to compare RTX with iv methylprednisolone (ivMP) in patients with active moderate to severe GO. Thirty-two patients were randomized to receive either ivMP (7.5 g) or RTX (2000 or 500 mg). The primary end point was the decrease of the clinical activity score of 2 points or to less than 3 at week 24. Changes of proptosis, lid fissure, diplopia and eye muscle motility, and quality of life score were secondary end points. The number of therapeutic responses, disease reactivation, and surgical procedures required during follow-up and the patients' quality of life were also assessed.

RESULTS

The clinical activity score decreased with both treatments but more after RTX at 16, 20, and 24 weeks (P < .04, P < .02, P < .006, respectively), whether 1000 mg RTX twice or 500 mg RTX once was used (P = NS). At 24 weeks 100% of RTX patients improved compared with 69% after ivMP (P < .001). Disease reactivation was never observed in RTX patients but was observed in five after ivMP. Patients treated with RTX scored better motility at 52 weeks in both the right (P = .014) and the left eye (P = .026). Overall rehabilitative surgical procedures carried out during follow-up (at 76 wk) were 12 in 16 ivMP patients and 5 in 15 RTX patients (P = .049).

CONCLUSIONS

The results of this trial confirm preliminary reports on a better therapeutic outcome of RTX in active moderate to severe GO, when compared with ivMP, even after a lower RTX dose. The better eye motility outcome, visual functioning of the quality of life assessment, and the reduced number of surgical procedures in patients after RTX seem to suggest a disease-modifying effect of the drug.

Prevalence and risk factors for thyroid eye disease among Korean dysthyroid patients

Purpose

To determine the prevalence of thyroid eye disease among dysthyroid Korean patients and to analyze the relationship between demographic data, lifestyle risk factors, and status of thyroid disease and thyroid eye disease.

Methods

All dysthyroid patients who visited endocrinology clinics in 24 general hospitals in Korea during a chosen one-week period were enrolled in this cross-sectional study. Data were collected during an interviewer-administered questionnaire and chart review. Demographic data, lifestyle risk factors, and status of thyroid disease variables were analyzed as risk factors using multivariable regression models to identify independent associations with thyroid eye disease.

Results

A total of 1,632 dysthyroid patients were included (1,301 females [79.7%] and 331 males [20.3%]). Two hundred eighty-three of these patients (17.3%) had thyroid eye disease. Multiple logistic regression analyses revealed that female gender, young age, Graves' disease, dermopathy, anti-thyroid medication treatment, and radioiodine treatment were independent risk factors for thyroid eye disease.

Conclusions

The lower prevalence of thyroid eye disease in dysthyroid Korean patients and the influence of gender on risk factors in this study are novel findings compared to studies performed involving Europeans. Although the risk factors for thyroid eye disease are understood in part, a more in-depth comparative study of gender and ethnic groups is needed to fully understand the biological significance of the demographic factors.

Update on advanced imaging options for thyroid-associated orbitopathy

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

Incidence and clinical presentation of moderate to severe graves' orbitopathy in a Danish population before and after iodine fortification of salt

CONTEXT

Population-based data on the incidence and clinical presentation of moderate to severe Graves' orbitopathy (GO) are scarce, and virtually nothing is known on the effect of an iodization program on the incidence and presentation of GO.

OBJECTIVE

The objective of the study was to characterize incident moderate to severe GO in North Jutland County, Denmark, during the period 1992-2009, before and after the Danish salt iodization program.

DESIGN AND PATIENTS

The design of the study was a prospective register of patients with incident moderate to severe GO in a population during 8.9 million persons × years of observation.

SETTING

The study was conducted at a thyroid-eye clinic of university hospital.

MAIN OUTCOME MEASURES

Clinical presentation and incidence before and after the year 2000 initiation of the mandatory Danish iodization of salt were measured. The incidence of GO was related to the incidence of Graves' hyperthyroidism (GH) in the same population.

RESULTS

The incidence rate of moderate to severe GO was 16.1/million per year (women: 26.7; men: 5.4), with no change associated with iodization of salt. The moderate to severe GO incidence was 4.9% of the incidence of GH. The incidence rate ratio between women and men with GO (4.9) was not different from the ratio in GH. Compared with GH, only a few patients (<2%) suffered from moderate and severe GO below the age of 40 yr, whereas GO was relatively common in age groups 40-60 yr (∼8%).

CONCLUSIONS

Approximately 5% of the patients with Graves' disease develop moderate to severe GO, with a similar risk in women and men with Graves' disease. The risk of GO is much higher in patients aged 40-60 yr than in young patients with Graves' disease. Salt iodization was not associated with a change in the incidence of GO.

Rituximab treatment in patients with active Graves' orbitopathy: effects on proinflammatory and humoral immune reactions

In active Graves' orbitopathy (GO), proinflammatory cytokines predominate. Circulating thyroid stimulating hormone (TSH)-receptor antibodies (TRAb) have been correlated with GO clinical activity and severity. In preliminary studies rituximab (RTX), an anti-CD 20 monoclonal antibody, has induced clinical improvement of active GO without a change in serum anti-thyroid antibodies. We have studied whether RTX in GO acts by affecting proinflammatory cytokines and thyroid and orbital-directed antibodies. Ten patients with GO were treated with RTX, administered twice intravenously (i.v.) (1000 mg) at days 1 and 15, and 20 with methylprednisolone, administered weekly i.v. (500 mg), for 16 weeks. Patients were studied before treatment, at B cell depletion and at 4, 8, 16, 20, 30 and 50 weeks. Peripheral lymphocytes, serum interleukin (sIL)-6, sIL-6r, chemokine (C-X-C motif) ligand 10 (CXCL10), TRAb and stimulating antibodies (TSAb) and autoantibodies against orbital calsequestrin, collagen XIII and flavoprotein subunit of succinate dehydrogenase (FP-SDH) were measured at baseline and after treatment. Serum IL-6 and sIL-6R concentrations did not change after RTX [P = not significant (n.s.)]. Serum CXCL10 increased after RTX at B cell depletion and at 30 weeks (P < 0·003). Serum TSAb did not change in relation to TRAb, nor did antibodies against orbital antigens (P = n.s.). In conclusion, this study shows that RTX in GO does not affect humoral reactions. The observed increase of serum CXCL10 concentrations at B cell depletion may result from cell lysis. We suggest that RTX may exert its effect in GO by inhibiting B cell antigen presentation.

Application of ultrasound in diagnosing and follow-up of endocrine orbitopathy

Endocrine orbitopathy or ophthalmopathy is an organ-specific, genetically conditioned autoimmune disease, resulting from a thyroid disorder. It is the most common cause of unilateral and bilateral proptosis in adults. Endocrine orbitopathy occurs most frequently in women aged 30 to 50 years. Ultrasound diagnostic is of primary importance in orbital pathology because of its safety, non-invasiveness, rapid application, and no need for preparation of the patient. The A scan in endocrine orbitopathy shows the echographical widening of the peripheral orbital space, a widening of the muscle echo, and the B scan shows a high internal echo of the connective tissue septa, increased reflection of the muscle belly, and distension of the retrobulbar optic nerve sheaths, enlargement of lacrimal gland and dilatation of the superior ophthalmic vein. All ultrasound features of the endocrine orbitopathy can be explained by immunological abnormalities and histological changes in orbital adipose tissue and extraocular muscles.

Update on thyroid eye disease and management

Thyroid eye disease is a heterogeneous autoimmune orbital reaction typically manifesting in middle age. The inflammation may parallel or remain isolated from a related inflammatory cascade in the thyroid called Graves' disease. The orbital manifestations can lead to severe proptosis, dry eyes, strabismus, and optic neuropathy. In this article, we will discuss this unique condition including the ophthalmic findings and management.

The course of endocrine ophthalmopathy during antithyroid therapy in a prospective study

In a prospective study the ocular manifestations of 105 thyrotoxic patients were carefully observed and registered during a 24-month antithyroid drug therapy. The treatment was supervised very closely and every effort was made to avoid iatrogenic hypothyroidism. None of the patients required any ocular surgery and in none did the ophthalmopathy become significantly worse. This favourable experience may indicate that a careful antithyroid regimen as outlined is not likely to be accompanied by worsening of the endocrine ophthalmopathy.

Oxidative stress and antioxidant activity in orbital fibroadipose tissue in Graves' ophthalmopathy

PURPOSE

To investigate the oxidative stress and antioxidant activity in the orbit in Graves' ophthalmopathy (GO).

MATERIALS AND METHODS

Orbital fibroadipose tissue samples were obtained from 13 cases during orbital fat decompression surgery. All cases demonstrated features of moderate or severe GO according to the European Group on Graves' Orbitopathy classification. The disease activity was evaluated with the Clinical Activity Score, and the clinical features of GO were evaluated with the Ophthalmopathy Index. Orbital fibroadipose tissue samples of 8 patients without any thyroid or autoimmune disease were studied as controls. In the tissue samples, lipid hydroperoxide level was examined to determine the level of oxidative stress; glutathione level to determine antioxidant level; superoxide dismutase, glutathione reductase, and glutathione peroxidase activities to determine antioxidant activity.

RESULTS

Lipid hydroperoxide level and all three antioxidant enzyme activities were found to be significantly elevated, while glutathione level significantly diminished in tissue samples from GO cases compared to controls (p < 0.05). Glutathione levels in tissue samples of GO cases showed negative correlation with Ophthalmopathy Index (r = -0.59, p < 0.05).

CONCLUSIONS

The antioxidant activity in the orbit is enhanced in GO. However, the oxidative stress appears to be severe enough to deplete the tissue antioxidants and leads to oxidative tissue damage. This study may support the possible value of antioxidant treatment in GO.

Planning health care for patients with Graves' orbitopathy

Background

To describe disease parameters of patients with Graves’ orbitopathy in a tertiary referral center in order to plan health care resource allocations. To investigate whether the clinical activity and/or the severity of the disease can be used as a predictor of the duration of treatment.

Methods

Retrospective, observational, non-comparative case series. One hundred and seventeen charts of GO-patients, randomly chosen out of a pool of 1600, referred to the Orbital Unit of the University Medical Centre Utrecht between 1 January 1992 and 1 January 2002, were analysed. Relevant parameters, such as age, gender, race, disease duration, smoking habits, concomitant diseases, previous treatment, symptoms and signs, number and sort of investigations, severity and activity scores, number and sort of treatments, treatment duration and outcome of treatment were retrieved and analysed. Disease activity and severity at entry were tested as possible predictors of disease duration and extent of treatment.

Results

Clinical profile at presentation; duration of the disease; extent of treatment; predictors of disease duration and of number of treatment interventions were the main outcome measures. Three percent of patients had Only Signs, but No Symptoms (OSNS), 61% had mild, 27% had moderately severe and 9% had severe GO. Fifteen percent had inactive disease at presentation, 65% had borderline activity and only 20% had active orbitopathy. Sixty percent complained about eyelid swelling and/or proptosis. The average period of eye treatment was 2.5 years (range: 0–110 months), during which patients were seen at an average of 8 times. Twenty percent needed no treatment at all. Fifteen percent were treated with nothing but lubricants and/or prisms. Twenty-five percent were treated with immunosuppressive modalities. Fifty-six percent underwent one or more surgical corrections. The Clinical Activity Score (CAS) was found to be significantly related to the duration of the treatment (p < 0.001), to the number of visits (p < 0.001), and to the number of surgical interventions (p < 0.001).

Conclusions

The majority of GO patients referred to a tertiary referral centre has no or borderline disease activity and ‘mild’ orbitopathy, disfiguring eyelids and proptosis being the most frequent complaints. The disease activity as assessed with the CAS can be used to predict the duration and extent of the treatment.

Treatment of Graves' disease and associated ophthalmopathy with the anti-CD20 monoclonal antibody rituximab: an open study

INTRODUCTION

Hyperthyroid Graves' disease (GD) is a B-cell-mediated condition caused by TSH receptor antibodies (TRAb), which decline when GD remits. Anti-CD20 monoclonal antibody rituximab (RTX) induces transient B-cell depletion that may potentially modify the active inflammatory phase of thyroid-associated ophthalmopathy (TAO).

METHODS

Nine patients with GD, (seven with active TAO, two with mild lid signs) were studied. The trial was only approved as an open pilot study; thus we compared the effect of RTX therapy to that of i.v. glucocorticoids (IVGC) in 20 consecutive patients. Patients were treated with RTX (1000 mg i.v. twice at 2-week interval) or with IVGC (500 mg i.v. for 16 weeks). TAO was assessed by the clinical activity score (CAS) and severity was classified using NOSPECS (No signs or symptoms; Only signs (lid); Soft tissue involvement; Proptosis, Extraocular muscle involvement; Corneal involvement; Sight loss). Thyroid function and lymphocyte count were measured by standardized methods.

RESULTS

All patients attained peripheral B-cell depletion with the first RTX infusion. Minor side effects were reported in three patients. Thyroid function was not affected by RTX therapy and hyperthyroid patients required therapy with methimazole. After RTX, the changes in the levels of thyroglobulin antibodies, thyroperoxidase antibodies and TRAb were neither significant nor correlated with CD20+ depletion (P = NS). CAS values before RTX were 4.7 +/- 0.5 and decreased to 1.8 +/- 0.8 at the end of follow-up (P < 0.0001) and more significantly compared with IVGC (P < 0.05). Proptosis decreased significantly after RTX both in patients with active TAO (ANOVA; P < 0.0001) and those with lid signs (ANOVA; P < 0.003). The degree of inflammation (class 2) decreased significantly in response to RTX (ANOVA; P < 0.001). Relapse of active TAO was not observed in patients treated with RTX, but occurred in 10% of those treated with IVGC, who also experienced adverse effects more frequently (45 vs 33% of patients).

CONCLUSIONS

RTX positively affects the clinical course of TAO, independently of either thyroid function or circulating antithyroid antibodies, including TRAb. If our findings are confirmed in large controlled studies, RTX may represent a useful therapeutic tool in patients with active TAO.

Evaluation and Management of Graves' Orbitopathy

Graves' orbitopathy, also known as Graves' ophthalmopathy or thyroid eye disease, is a potentially progressive but generally self-limited autoimmune process associated with hyperthyroidism. It is the most common cause of proptosis and the most common orbital inflammatory disorder in adults.

Transcaruncular orbital decompression: an alternate procedure for Graves ophthalmopathy with compressive optic neuropathy

PURPOSE

To study the efficacy of transcaruncular orbital apex decompression for Graves ophthalmopathy with compressive optic neuropathy nonresponsive to pulse corticosteroids.

DESIGN

Retrospective, interventional case series study.

METHODS

From August 1999 to November 2003, transcaruncular orbital decompression was performed in 22 consecutive Graves ophthalmopathy patients with compressive optic neuropathy refractory to pulse corticosteroids. The average period of corticosteroid treatment was 16.1 +/- 5.2 days. Main outcome measures were preoperative and postoperative best-corrected vision, Hertel exophthalmometry, 100-hue color sensation test, visual evoked potential, visual field, and new-onset diplopia.

RESULTS

Visual acuity improved significantly from 1.08 +/- 0.24 logarithm of minimal angle of resolution (logMAR) preoperatively to 0.29 +/- 0.18 logMAR postoperatively (P < .0001). Average improvement in retinal sensitivity was 9.4 +/- 8.2 dB, in P(100) value of visual evoked potential was 27.5 +/- 20.1, and in "total errors" of the 100-hue test was 309.9 +/- 214.3 after surgery. Average retroplacement effect was 3.7 +/- 1.6 mm. Statistical analysis showed significant differences between preoperative and postoperative measurements for all above parameters (P < .0001). New-onset diplopia occurred in 38% of patients. There were no complications specifically attributable to the transcaruncular technique.

CONCLUSIONS

The transcaruncular approach offers access to the medial and inferior wall for orbital apex decompression in Graves ophthalmopathy patients with compressive optic neuropathy refractory to pulse corticosteroids. Advantages over other approaches included no external scar, less damage to adjacent tissue, and wide exposure to the entire medial wall.

Ophthalmological evaluation in thyroid-associated ophthalmopathy

PURPOSE

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

RESULTS AND CONCLUSIONS

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

[Does thyroidectomy worsen Graves'ophtalmopathy?]

AIM OF THE STUDY

To determine if thyroïd surgery increase or not the eye symptoms in patients with Graves'ophtalmopathy.

MATERIALS AND METHODS

This retrospective study included between 1981 and 2001 two groups of patients: - group 1 : 24 patients who underwent thyroid surgery, - group 2 : 13 patients who were treated only by antithyroid drugs. Eye signs were evaluated according to the "NOSPECS" classification. The effect of the thyroid surgery and the medical treatment were evaluated with the NOSPECS classification modified by Orgiazzi in order to allow quantitative comparative data. The reasons why the patients were refered to surgery were:- the important size of the goitre (n = 10), - a recurrent hyperthyroidy despite an appropriated medical treatment (n = 10), - a pregnancy desire (n = 2), - a worsening of the eye signs (n = 2). Eighteen subtotal thyroidectomies and 6 total thyroidectomies were performed.

RESULTS

after thyroid surgery, ophtalmic status was noted to improve in 18 patients, to remain inchanged in 1 patient and to deteriorate in 5 patients. In the non-operated group, the results were quite similar, but the mean goitre size was statistically lower and the ophtalmic lesions were statistically appearing later, these two parameters traducting a less serious disease in this group.

CONCLUSIONS

This study suggests that thyroidectomy doesn't worsen the eye symptoms in patients with Graves'ophtalmopathy.

Orbital gallium-67 scintigraphy in Graves' ophthalmopathy

Assessment of orbital disease activity in patients with Graves' ophthalmopathy is important in planning the therapeutic approach. In this study, orbital uptake of gallium-67 citrate ((67)Ga) was evaluated in 46 consecutive patients demonstrating active or inactive Graves' ophthalmopathy. The disease activity with Graves' ophthalmopathy was evaluated by using clinical activity score (CAS). Orbital (67)Ga scintigraphies of 8 patients without any history of ophthalmic, thyroid, or autoimmune disease were studied as controls. (67)Ga scintigraphy was performed 48 hours after intravenous injection of 4 mCi (128 MBq) of radioactive complex. Single-photon emission computed tomography (SPECT) images were obtained with a gamma camera. Intravenous corticosteroid treatment was given to 8 selected patients demonstrating bilateral active orbital disease and (67)Ga scintigraphy was repeated 6 months after the treatment. Quantitative analysis of mean orbital (67)Ga uptake demonstrated significant difference between active, inactive, and control groups (p = 0.0001). The orbital uptake of (67)Ga was significantly elevated in the active group compared to the inactive and control groups. A threshold orbital (67)Ga uptake value was calculated to differentiate active and inactive groups based on receiver operating characteristic (ROC) analysis. A significant correlation was found between the CAS and the (67)Ga orbital uptake (r = 0.73, p = 0.0001). Clinical improvement and significant decrease in orbital (67)Ga uptake were achieved after immunosuppressive treatment (p = 0.0004). These preliminary results suggest that orbital (67)Ga scintigraphy may provide objective assessment of the disease activity in Graves' ophthalmopathy.

Serial STIR magnetic resonance imaging correlates with clinical score of activity in thyroid disease

PURPOSE

To assess the correlation between inflammatory activity in extraocular muscles measured with serial short tau inversion recovery (STIR) sequence magnetic resonance imaging (MRI) scans and clinical disease activity in thyroid eye disease.

METHODS

In this retrospective study, 22 patients with thyroid eye disease who had undergone serial MRI scans using the STIR sequence were assessed. The signal intensity ratio (SIR) of the most inflamed extraocular muscle was compared with the Mourits score (a clinical measure of thyroid eye disease activity).

RESULTS

The SIR value has previously been shown to correlate with clinical activity of thyroid eye disease. In a particular patient the SIR value increases in proportion with the clinical features of the disease as assessed by the Mourits rating system. When the change in STIR sequence MRI is compared with the change in Mourits score rating for a given patient the correlation is highly significant (p < 0.001).

CONCLUSIONS

This study confirms that serial STIR sequence MRI scans correlate with clinical disease activity. Inflammatory activity in the most inflamed muscle (as measured by SIR) reflects overall disease activity. SIR values obtained from MRI scans provide a useful measure of disease activity and may help in the monitoring and treatment of this condition.

Thyroid eye disease

Thyroid eye disease is the most common cause of unilateral and bilateral proptosis in adults. It occurs most frequently in women aged 30 to 50 years. Clinical features include eyelid retraction, periorbital edema, conjunctival injection and chemosis, proptosis, extraocular muscle restriction, exposure keratopathy, and optic nerve compromise. Thyroid eye disease differs from idiopathic orbital myositis in that the latter is characterized by a more acute onset, more severe pain, and a rapid response to systemic corticosteroid therapy. Echography and computed tomography in thyroid eye disease reveal enlarged extraocular muscle bellies with relative sparing of the tendons. Despite evidence of an immune-mediated cause, the precise pathophysiologic mechanisms of thyroid eye disease remain unknown.

Place of radiotherapy in the treatment of Graves' orbitopathy

PURPOSE

The aim of this study is to evaluate the response of Graves' orbitopathy to irradiation, and to specify the prognostic factors allowing one to better define the indications of orbital radiotherapy.

METHODS AND MATERIALS

From 1977 to 1996, 199 patients received bilateral orbital irradiation delivering 20 Gy in 10 fractions and 2 weeks for a progressive Graves' orbitopathy. 195 patients were seen between 1 and 6 months after radiotherapy. The different symptoms were studied and their response to radiation was analyzed. Factors such as age, sex, evolution of thyroid disease, history of symptoms, and previous or combined treatments were analyzed.

RESULTS

The results revealed that 50 patients (26%) had a good or excellent response, 98 (50%) had a partial response, 37 (19%) were stable, 10 (5%) had a progression of disease. The signs that best responded to radiotherapy were the infiltration of soft tissues and the corneal involvement. Responses of proptosis or oculomotor disorders were more complete when these signs were not advanced at the time of treatment. Irradiation seemed to have the same efficacy when applied as first-line treatment or after failure of corticosteroids. Neither modality of treatment of hyperthyroidism nor thyroid status at the time of orbital irradiation modified the results. The best results were recorded for early or moderately advanced presentation (p = 0.05). Patients treated within a delay of 7 months after the beginning of the ophthalmopathy had better responses than patients treated later (p = 0.10).

CONCLUSION

Radiation therapy was successful in Graves' orbitopathy by stopping the progression of disease in almost all cases, by improving the comfort of patients, by obtaining objective responses, and by avoiding surgical treatments particularly when signs were moderate.

Comparison of serum thyrotrophin concentrations determined by a third generation assay in patients with various types of overt and subclinical thyrotoxicosis

OBJECTIVE

Recent increases in the sensitivity of methods used to measure TSH, especially third generation assays, have enabled separation of partial from complete pituitary suppression in patients with thyrotoxicosis. We have investigated the use of a sensitive chemiluminescent enzymeimmunoassay in the differential diagnosis of thyrotoxicosis.

DESIGN AND PATIENTS

Serum TSH concentrations were determined by chemiluminescent enzymeimmunoassay in patients with various types of overt and subclinical thyrotoxicosis.

RESULTS

The assay was highly sensitive with an analytical sensitivity of 0.0016 mU/l. Among 45 hyperthyroid patients with untreated Graves' disease, 37 (82.2%) showed undetectably low levels (< 0.002 mU/l). Serum TSH in the remaining 8 patients (17.8%) was 0.003-0.005 mU/l. In contrast, TSH was undetectably low in only 5 (20.0%) of 20 patients with painless thyroiditis and in 2 (12.5%) of 16 patients with subacute thyroiditis. Eleven (55.0%) with painless thyroiditis and 12 (75.0%) with subacute thyroiditis had TSH values greater than 0.005 mU/l (0.006-0.032 and 0.006-0.228 mU/l, respectively; normal range 0.5-5.0 mU/l). Serum TSH levels were subnormal in 10 of 12 patients with euthyroid ophthalmic Graves' disease, including 4 with undetectably low levels. Among 11 patients with an autonomously functioning thyroid nodule 6, including 1 with normal free T4 and free T3 and 2 with normal free T3, showed TSH values less than 0.002 mU/l. No significant correlation was observed between serum free T4 or free T3 and TSH concentrations in thyrotoxic patients. Together with the incomplete suppression of TSH observed in those with destructive thyroiditis, this suggests that the grade of TSH suppression was influenced by the duration of illness at the time of blood sampling.

CONCLUSION

The third-generation TSH assay is useful for the differential diagnosis of various types of thyrotoxicosis, especially between Graves' disease and destructive thyroiditis.

[Endocrine orbitopathy: comparison of the long-term result and classification after radiotherapy]

BACKGROUND

This study compares 4 classifications in patients with progressive refractory Graves orbitopathy (GO) and examines their prognostic value in long-term follow-up.

PATIENTS AND METHODS

From 1984 to 1994, 60 consecutive patients (49 female, 11 male) received 20 Gy (10 x 2 Gy) radiotherapy with 6 MV Linac photons. Ocular symptoms and functional impairment was evaluated according to 4 GO-classification systems: Werner-, modified ATA- and Stanford-Score and Ophthalmopathy-Index (OI) according to Grussendorf. In addition, all patients noted their subjective response on a linear scale (0 to 100%).

RESULTS

Improvement was achieved within 1 year after radiotherapy according to the Werner-Score in 28 (47%) patients in > or = 1 symptom category, according to the modified ATA-score in 48 (80%), the Stanford-score in 47 (78%) and the OI-Score in 55 (92%) patients (reduction of > 2 points). The Werner-Score correlated less to the other scores (coefficient r < 0.5) than the other scores among themselves (r approximately 0.9). The ATA-Score improved in the different symptom categories between 47% (stage VI) and 87% (stage V). The OI-Score was reduced by a mean of 6 points. The patients reached a mean subjective improvement of +70 +/- 25%. Acute or chronic side effects were not observed. In multivariate analysis the "male gender" (p = 0.08), a "symptom duration prior to radiotherapy > 1 year" (p = 0.14) and a "high symptom category" (p = 0.11) indicated a negative prognostic trend.

CONCLUSIONS

External radiotherapy is effective for severe, progressive GO after pretreatment. A minimum follow-up of at least 12 months and standardized classification and success criteria are required.

Diagnostic classification of autoantibody repertoires in endocrine ophthalmopathy using an artificial neural network

PURPOSE

The aim of this study was to classify the human IgG autoantibody repertoire of sera from patients suffering from endocrine ophthalmopathy (EOP) and healthy subjects (CTRL) for diagnostic purposes using the recently developed Megablot technique. This technique allows for the simultaneous and quantitative screening of a large set of antigens and uses multivariate statistical techniques and an artificial neural network.

METHODS

Sera were tested against Western blots (WBs) of SDS-PAGE preparations of proteins from human extraorbital eye muscle (EOP: n = 16; CTRL: n = 11). Digital image analysis was performed. The blots were subsequently analyzed by multivariate statistical techniques (analysis of discriminance) and an artificial neural network (probalistic neural network).

RESULTS

The sera of both the EOP and CTRL groups showed a complex staining pattern against WBs of SDS-PAGEs from human eye muscle. Using the multivariate statistical technique for classification, all of the known samples and 85% of the unknown samples (not presented during calculation) were assigned to their correct clinical group. Using the artificial neural network as classifier, all of the samples presented during training and 96.3% of the unknown samples (not trained) were assigned correctly.

CONCLUSIONS

The artificial neural network exceeds the ability of multivariate statistical techniques such as analysis of discriminance to assign unknown samples to their correct predefined group. Thus, the neural network exceeds other methods in generalizing some similarities of blots used for classification. This study reveals that our new technique and its evaluation using a neural network can be used as a helpful diagnostic tool in autoimmune diseases such as endocrine ophthalmopathy.

Long-term results of four-wall orbital decompression for Graves' ophthalmopathy

A long-term (average 5 years, 4 months) follow-up of four-wall orbital decompression for Graves' ophthalmopathy in 22 patients is presented. Surgical decompression was reserved for patients who failed to respond to medical therapy. Six patients had undergone previous limited surgical decompression (3-wall decompression in one patient, 2-wall decompression in 4 patients, and orbital floor resection in 1 patient). All patients had moderate to severe proptosis. Fifteen of the 44 eyes (34%) had visual acuity of 20/200 or less. There were only 6 eyes with normal visual acuity (20/20) preoperatively (13.6%). Postoperatively visual acuity was normal in 34 eyes (77%). Globe recession varied from 2 to 14 mm (mean 6.1 mm). Apart from diplopia, symptomatic improvement was noted in nearly all patients.

Clinical features of patients with Graves' disease undergoing remission after antithyroid drug treatment

The clinical course of 306 Graves' patients treated with methimazole (MMI) was reviewed with the aim of establishing criteria able to predict remission of hyperthyroidism after medical treatment. One hundred and ninety-four (149 females, 45 males) of 306 (63.4%) patients had relapse of hyperthyroidism after antithyroid drug (ATD) withdrawal. Relapse was more frequent during the first months of the follow-up, but still it was observed 3 years after MMI withdrawal. The relapse rate was dependent on the age of the patient, the size of goiter, and the level of TSH-receptor antibody (TRAb) at diagnosis, being observed in 40 of 47 (85%) patients with high (> 30 U/L) TRAb level and in 54 of 101 (53%) patients with low TRAb level (< or = 30 U/L; p <.0002). Remission was more frequent (43.3%) in patients having the combination goiter size < or = 40 mL, TRAb level < or = 30 U/L, than in patients with goiter size > 40 mL and high TRAb levels (9%). In the subgroup of patients with the combination: goiter < or = 40 mL- TRAb < or = 30 U/L - age at onset > 40 years, the remission rate was 80%, and all relapses occurred within the first 9 months after MMI withdrawal. In conclusion, our study confirms that hyperthyroidism relapses in the majority of patients with Graves' disease treated with ATD. Among different clinical and laboratory features, age at onset of hyperthyroidism, goiter size and TRAb level are particularly helpful in identifying those patients who are more prone to undergo a remission of hyperthyroidism after medical treatment and may be useful to select the minority of Graves' patients who will benefit from antithyroid drug treatment as a first choice.

Subclinical Graves' disease as a cause of subnormal TSH levels in euthyroid subjects

In order to elucidate causes of subclinical thyrotoxicosis, we reviewed records of thyroid function tests obtained in our hospital between 1990 and 1992 showing normal thyroid hormones and subnormal TSH levels, and analyzed underlying clinical conditions of the patients. Of 186 patients with normal T4 and/or free T4 and normal T3 and/or free T3 but subnormal TSH (< 0.1 mU/l) levels in serum, 150 were under treatment with antithyroid drugs for hyperthyroid Graves' disease or with thyroid hormones for hypothyroidism. Twelve were in remission after treatment for Graves' disease, and 4 had destructive thyroiditis. Of the remaining 20 patients, 4 had autonomously functioning thyroid nodule (AFTN), 9 had euthyroid ophthalmic Graves' disease (EOG), and 7 had diffuse goiter without apparent ophthalmopathy (DG). When thyroid stimulating antibodies (TSAb) were measured in the last 3 groups of the patients, they were detected in none with AFTN but in all patients with EOG and DG. These 7 DG patients without ophthalmopathy had a clinical feature showing unstable thyroid functions, changeable to euthyroidism, overt hyperthyroidism and even hypothyroidism during follow-up. In conclusion, TSAb measurement is useful for detection of subclinical Graves' disease in euthyroid subjects with subnormal TSH levels in serum.

Echographic monitoring of response of extraocular muscles to irradiation in Graves' ophthalmopathy

PURPOSE

Confirmation of the efficacy of orbital irradiation in Graves' ophthalmopathy is needed due to the unpredictable natural history of the disease, the variation in individual clinical presentations, the contribution of other simultaneous treatments, and the lack of controlled studies using objective criteria to classify and assess response over time. Orbital echography before and at select intervals following orbital irradiation is proposed as an objective parameter of tissue response to orbital irradiation over time.

METHODS AND MATERIALS

From January, 1983 to September, 1993, 55 patients with progressive Graves' ophthalmopathy underwent 20 Gy retrobulbar irradiation. On retrospective review, standardized orbital echography was performed randomly prior to irradiation in 37 of the 55 patients to assess the acoustic characteristics of the extraocular muscles and to quantitate their individual and summed diameters. Twenty-one patients had at least one follow-up echographic evaluation at random intervals of 0 to 27.5 months following completion of irradiation. Twelve patients received steroids before or during irradiation, which were tapered in proximity to completion of radiation. Follow-up ranged from 2 to 65 months with the majority followed at least 6 months (18 patients).

RESULTS

Of the 21 patients with serial studies, 18 showed an interval decrease in individual and summed muscle size over time and return of symmetry. Interval improvement was documented as early as the 1 month follow-up study, with continued improvement seen during the 3-9-month studies, with stability typically achieved within 12 months. One patient had further changes between the 21 and 27.5 month follow-up studies. Exacerbation of disease was, however, echographically demonstrated in three patients at 6.5, 8.5, and 13 months. Follow-up studies in two of these patients again revealed improvement, one following tapered steroids. The third patient required orbital decompression.

CONCLUSION

Objective parameters of response are needed to document both the immediate and long-term outcome of orbital irradiation on the course of Graves' ophthalmopathy and confirm its efficacy. Serial echography is proposed as a new technique for providing parameters to judge response.