The 2021 European Group on Graves' orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves' orbitopathy

N6-methyladenosine modification of THBS1 induced by affluent WTAP promotes Graves' ophthalmopathy progression through glycolysis to affect Th17/Treg balance

Graves' ophthalmopathy (GO) obvious manifestation is the imbalance of Th17/Treg. N6-methyladenosine (m6A) methylation is an important regulator of Th17/Treg balance. However, few reports narrate how m6A regulators mediate the role of genes in GO progression. We explored the m6A modification of THBS1 mediated by WTAP, and the mechanism by which THBS1 regulated glycolysis and Th17/Treg balance. A total of 12 peripheral blood (4 GO samples, 4 GH samples, and 4 health samples) were collected to measure the percentage of Th17/Treg in monocytes by flow cytometry. RNA sequencing (RNA-seq) combined with MeRIP sequencing (MeRIP-seq) was used to screen differentially expressed and methylated genes. MeRIP-qPCR was performed to evaluate the m6A abundance of THBS1 after WTAP silencing. Glycolysis of CD4+ T cells was reflected by the lactate content and glucose uptake. The number of Th17 cells was increased in GO peripheral blood, whereas the Treg cells decreased. RNA-seq acquired 679 differentially expressed genes (308 up-regulated, and 371 down-regulated) in the CD4+ T cells of GO compared to healthy control. MeRIP-seq identified 3277 m6A peaks between the GO group and the healthy control group, corresponding with 2744 genes (1143 hypermethylated and 1601 hypomethylated). Combined analysis of RNA-seq and MeRIP-seq showed 81 hypermethylated and up-regulated genes. Among the six candidate genes in the PI3K-signaling pathway, THBS1 was the most significantly differentially expressed and hypermethylated. THBS1 silencing resulted in decreased lactate content and glucose uptake in CD4+ T cells. WTAP was significantly upregulated in CD4+ T cells of GO, and WTAP silencing significantly reduced m6A abundance and expression of THBS1. Upregulated and hypermethylated THBS1 mediated by WTAP promoted glycolysis of CD4+ T cells, affected Th17/Treg balance, and facilitated GO progression. We provided a novel potential target for GO treatment and revealed the molecular mechanism of WTAP and THBS1 in GO under the m6A perspective.

Contrast-enhanced orbital MRI for activity assessment and treatment response prediction in thyroid eye disease

OBJECTIVE

To investigate the performance of contrast-enhanced orbital MRI (T1-weighted contrast-enhanced [T1CE] and dynamic contrast-enhanced MRI [DCE-MRI]) for activity assessment and prediction of treatment response to intravenous glucocorticoid (IVGC) treatment in thyroid eye disease (TED).

METHODS

A retrospective study of 59 active moderate-to-severe TED patients (36 responsive and 23 unresponsive) treated with IVGC, matched with 31 inactive TED patients were included. T1CE and DCE-MRI were collected from each subject. Univariate and multivariate logistic regression analyses, as well as receiver operating characteristic (ROC) curves (evaluated by area under the curve, AUC) were used to evaluate the diagnostic and predictive models.

RESULTS

Active patients showed a higher signal intensity ratio of lateral rectus (LR-SIR) on T1CE and a higher wash-in rate of inferior rectus (IR-WIR) on DCE-MRI compared to inactive patients (p < 0.05). The AUC for T1CE and DCE-MRI based models were 0.866, and 0.844, respectively. The combined model (LR-SIR and IR-WIR) significantly enhanced model performance (AUC = 0.914, 95 % CI: 0.858-0.970). Responsive patients demonstrated a longer time to peak of lateral rectus (LR-TTP) than unresponsive patients (p < 0.05). The cutoff value of prediction probability was 0.678, and the AUC based on this model was 0.739 (95 % CI: 0.608-0.807).

CONCLUSIONS

T1CE and DCE-MRI could effectively assist in TED activity assessment, and DCE-MRI could help predict IVGC treatment response. Specifically, LR-SIR and IR-WIR were indicators of TED activity, and IR-TTP was predictive of IVGC treatment response. Combining both contrast-enhanced sequences could further enhance the efficiency of TED activity assessment.

Teprotumumab Improves Quality of Life in Thyroid Eye Disease: Meta-analysis and Matching-adjusted Indirect Comparison

Context

Teprotumumab and/or intravenous methylprednisolone (IVMP) are first-line treatments for thyroid eye disease (TED)/Graves' orbitopathy. Direct comparisons of these treatments on Graves' Orbitopathy Quality of Life Questionnaire (GO-QoL) are lacking.

Objective

Systematic review, meta-analysis, and matching-adjusted indirect treatment comparison (MAIC) of GO-QoL improvements.

Methods

A literature search was performed using PubMed and Embase between inception to April 1, 2023, including studies of patients with moderate to severe active TED treated with teprotumumab or IVMP.Changes in GO-QoL scores and appearance and visual function subscales were extracted. Two teprotumumab (n = 84) and placebo (n = 87) randomized clinical trials and 5 studies with IVMP (4.5 mg/12 weeks, n = 304) were identified. MAIC compared teprotumumab/placebo by adjusting for baseline GO-QoL, diplopia, proptosis, smoking, age, and sex. Significant improvements in overall GO-QoL were observed for teprotumumab vs IVMP [mean difference (MD): 13.26; 95% confidence interval (CI): 7.44, 19.09) and placebo (MD: 12.57; 95% CI: 5.94, 19.21), but not IVMP vs placebo (MD: -2.06; 95% CI: -8.24, 4.12). Improvements were noted in appearance subscale GO-QoL for teprotumumab vs IVMP (MD: 7.50; 95% CI: 0.35, 14.64) and placebo (MD: 10.80; 95% CI: 3.62, 17.98) but not for IVMP vs placebo (MD: 0.91; 95% CI: -6.36, 8.18). Visual subscale GO-QoL displayed greater improvements for teprotumumab vs IVMP (MD: 17.66; 95% CI: 7.86, 27.47) and placebo (MD: 14.54; 95% CI: 6.10, 22.99), with no significant change for IVMP vs placebo (MD: -3.65; 95% CI: -12.88, 5.57). Orbital pain, teprotumumab treatment, diplopia, proptosis, and male sex were significant independent predictors of overall GO-QoL (P < .05).

Conclusion

This unique analysis demonstrated a more clinically meaningful improvement in the health-related quality of life, as measured by the GO-QoL, for TED patients with teprotumumab vs both the most recommended IVMP dosage and placebo.

Exploration of the relationship between Graves' eye disease and type 2 diabetes based on biomarkers

PURPOSE

The development of Graves' ophthalmopathy (GO) is silent and can be accompanied by type 2 diabetes (T2D). However, the early diagnosis of these two conditions remains difficult.

METHODS

We evaluated a total of 123 patients with T2D and GO and 128 patients with GO treated in our hospital from 01 May 2016 to 31 May 2022. We determined the levels of several biomarkers and developed a regression model to evaluate the diagnostic efficacy of these biomarkers.

RESULTS

Univariate analysis showed that age and thyroid-stimulating hormone (TSH), free triiodothyronine (FT3), free thyroxine (FT4), glycated haemoglobin (HbA1c), and fasting glucose levels were significantly different in the GO-T2D group compared with the GO group. In the multivariate logistic regression analysis, FT3 and FT4 levels lost their statistical significance when the other factors remained unchanged. Older age and higher TSH, HbA1c, and glucose levels were associated with an increased likelihood of having GO-T2DM. The regression model for diagnosing GO and GO-T2D presented an R2 of 0.70, a sensitivity of 87.80%, a specificity of 93.75%, and an area under the receiver operating characteristic (ROC) curve of 0.97.

CONCLUSION

Age and TSH, HbA1c, and glucose levels are effective predictors of GO and GO-T2D. Therefore, routine examination of these biomarkers in patients with GO could help to diagnose T2D early, thus allowing early treatment and a better prognosis.

Low clinical activity score, 'progressive' thyroid eye disease: presentations of 1439 patients from a tertiary centre in Hong Kong

BACKGROUND

To report the presenting clinical, serological and treatment profiles of 1439 patients with thyroid eye disease (TED) from a tertiary centre in Hong Kong.

STUDY POPULATIONS

Consecutive patients with TED presented to the Thyroid Eye Clinic (TEC), the Chinese University of Hong Kong between 2014 and 2023.

METHODS

Prospective cohort and masked review of medical records and orbital images.

RESULTS

A total of 1439 (70% female, 98% Han Chinese) patients with TED (26% ex/current smoker), presented at 43±5.9 years old, were reviewed. The first TED symptoms to TEC evaluation was 6±3 months. 85% had Graves' disease and 12% were given radioactive iodine before presentation. 35% of patients had a family history of autoimmune thyroid diseases. Baseline thyroid-stimulating hormone receptor antibody, thyroid-stimulating immunoglobulin and thyroid peroxidase antibody were elevated in 75%, 69% and 57% tested. Euthyroid TED (E-TED) was diagnosed in 6%, associated with asymmetric presentation (p<0.001). The most common signs were exophthalmos (69%), upper eyelid retraction (53%), swelling (36%), conjunctival injection (34%) and lower eyelid retraction (32%). Notably, 547 (38%) presented with moderate-to-severe and 150 (10%) vision-threatening TED, whose clinical activity score (CAS) was just 2.4±1.4 and 2.6±1.5, respectively. Male and TED onset after 40 were associated with higher CAS and NOSPEC (No physical signs or symptoms, Only signs, Soft tissue involvement, Proptosis, Extraocular muscle signs, Corneal involvement, and Sight loss) score (both p<0.05). 471 (33%), 361 (25%), 263 (18%) and 138 (9%) patients received intravenous methylprednisolone, orbital radiotherapy, steroid-sparing immunosuppressants and surgical decompression, respectively.

CONCLUSIONS

Around one-third (34%) of our cohort presented with 'low-CAS, progressive', moderate-to-severe or vision-threatening TED, while only one-fifth (18%) were clinically active (CAS≥3). Our results showed the limitations and unmet need of the existing 'high-CAS only' approach, especially in managing 'non-inflammatory' TED, prevalent in non-Caucasian populations.

Rituximab for a rare pediatric case of concurrent thyroid eye disease and myasthenia gravis

Rituximab (RTX) is a humanized chimeric anti-CD20 monoclonal antibody that leads to immunosuppression through rapid depletion of B lymphocytes. It has been demonstrated to be useful in treating both thyroid eye disease (TED) and myasthenia gravis (MG), respectively. However, the effectiveness of RTX in concurrent TED and MG cases is unclear and not previously reported in the literature. In this study, we describe a 13-year-old girl who presented with a 10-year history of general MG and a 1-year history of Graves' disease, bilateral proptosis, eye motility restriction, and lagophthalmos. A comprehensive evaluation confirmed the diagnosis of concurrent TED and MG. Satisfactory effectiveness was observed after RTX treatment without side effects. Based on the described observations, we suggest that RTX should be further explored as a treatment option for patients with concurrent TED and MG.

Regional Differences in the Management of Thyroid Eye Disease: Results from an International Clinical Practice Survey of Endocrinologists

Background: Over the past several decades, there have been indications of potential shifts in the diagnostic strategies and treatment of patients with Graves' disease (GD) and thyroid eye disease (TED). The objective of this study was to evaluate current practices in managing GD when complicated by moderate-to-severe TED worldwide. Methods: We recently reported results from a global online survey of endocrinologists comparing the management of GD in different scenarios. The current analysis focuses on regional differences in the diagnosis and treatment of GD when complicated by TED. Results: A total of 1252 respondents from 85 countries completed the survey. Regarding the initial diagnostic and treatment measures, there were no differences among the various geographical regions. Regarding the treatment of moderate-to-severe TED, the use of sodium selenite was higher in Europe (66.5%) and Oceania (60%) compared to other regions (p < 0.001). North American respondents were more likely to recommend teprotumumab and less likely to use glucocorticoids (p < 0.001). When comparing the treatment options for GD in patients with TED, although prolonged use of antithyroid drugs (ATD) remained the first choice in all regions, respondents from Europe, North America, and Oceania were more likely to recommend thyroidectomy than those from other regions (p < 0.001). Ophthalmologists, rather than endocrinologists, would more often be responsible for prescribing advanced medical therapy for TED in North America, Oceania, and Africa, while endocrinologists would have primary responsibility in other regions of the globe. Conclusions: Although there are regional differences, respondents generally employ the recommended diagnostic tools, treatments, and a multidisciplinary approach suggested by current clinical practice guidelines. However, there were examples of deviations from current guidance from professional societies.

Tryptophan metabolites exert potential therapeutic activity in graves' orbitopathy by ameliorating orbital fibroblasts inflammation and proliferation

PURPOSE

Graves' orbitopathy (GO) is a sight-threatening organ-specific autoimmune disease with complicated pathogenesis. Gut microbiota-derived tryptophan (Trp) metabolites play important roles in immune-related diseases, but their role in GO remains unknown.

METHODS

Trp metabolism-associated gut flora was analyzed by 16 S sequencing in GO patients and controls. Serum metabolomics profiling was performed to assess Trp metabolic pathway. Trp metabolites levels were measured by ELISA in 401 serum samples from a case-control study, and their effects on inflammation and proliferation in orbital fibroblasts were evaluated in vitro.

RESULTS

Trp metabolism-associated gut flora, including phylum Firmicutes and genus Anaerostipes, were significantly down-regulated in GO patients. Serum metabolomics revealed significant enrichment of Trp metabolic pathway in both GO and Graves' disease (GD) groups. Serum levels of indolepropionic acid (IPA), indole-3-lactate (ILA), and indoleacetic acid (IAA) were significantly decreased in both GD and GO patients compared to controls, with IAA levels further reduced in GO compared to GD patients. Notably, active GO patients had significantly lower IAA levels compared to inactive ones. Moreover, the levels of IAA were negatively correlated with clinical activity score and serum thyrotropin receptor antibody (TRAb) in GO patients. In vitro, IPA, ILA, and IAA mitigated TNFα-induced inflammation and proliferation in orbital fibroblasts by suppressing the Akt signaling pathway.

CONCLUSION

Trp metabolites IAA maybe a novel biomarker for GO progression. And IPA, ILA and IAA may play a protective role in GO by regulating inflammation and proliferation in orbital fibroblasts, suggesting their potential as therapeutic targets for GO treatment.

Thyroid eye disease in the biologic era: a 40-year paradigm shift in nonsurgical therapeutic strategies

BACKGROUND

Over the last four decades, there has been a progressive increase in the number of publications and citations on research related to thyroid-associated ophthalmopathy (TAO) nonsurgical treatment across many countries/regions, institutions, and authors, with a special focus on biological immunotherapy.

RESEARCH DESIGN AND METHODS

Examing 1600 publications collected from the Web of Science Core Collection database on TAO research from 1983 to 2023, our bibliometric analysis evaluated various bibliometric indicators, among which some important subtopics were identified and further discussed and reviewed.

RESULTS

The study showed that novel insights into the pathogenesis of TAO and new immunological targets for nonsurgical treatments were the major research focus over the past 40 years. Especially, targeted biological immunotherapies were on the rise, promoting treatments efficacy and patients' quality of life.

CONCLUSIONS

Our study provided a thorough overview and visual presentation of the evolutionary landscape and emerging frontiers for nonsurgical treatment of TAO surrounding its immunological mechanism and therapeutic strategy. It also shed light on its global collaboration patterns, current trends and research hotspots, hopefully to facilitate collaborative initiatives and guiding future research.

Radiological Activity Score (RAS)-MRI Characteristics in Dysthyroid Optic Neuropathy in a Multi-Ethnic Thyroid Eye Disease Population

PURPOSE

Dysthyroid Optic Neuropathy (DON) is a sight threatening and diagnostically challenging complication of Thyroid Eye Disease (TED). We provide a comparative analysis of the MRI features associated between patietnts with and without DON.

METHODS

Anonymised retrospective cohort study of patients with TED over eleven years. All patients had Axial T1-weighted and coronal 3 mm MRI STIR images. In a subset, a 3-mm-thick non-echoplanar HASTE DWI sequence was acquired in the coronal plane, and an ADC map was calculated using the diffusion scan raw data. Assessment of apical crowding (AC), extraocular muscle (EOM) enlargement (E), peri-muscular fat (PMF)/muscle signal intensity (SI) and Apparent Diffusion Coefficient (ADC) were analysed on coronal images.

RESULTS

Twenty-six consecutive DON and 516 non-DON cases. In the DON group, elevated EOMSI, PMFSI, EOME and AC were present in 54.6%, 25.9%, 72.7% and 64.6%, respectively, compared to 24.1%, 6.2%, 42.1% and 5.9% in the non-DON (p = 0.001, p = 0.000, p = 0.001 and p = 0.000). The average ADC value in the DON cohort was 1373 ± 319 versus 973 ± 237 in the non-DON (p = 0.000). Likelihood of DON on Univariable Regression Analysis (Odds Ratios): Apical Crowding (29.1 x p = 0.000) and ADC Value ≥ 1200 (7.3 x p = 0.000). On Multivariable Regression Analysis (Odds Ratios): Apical Crowding 22.1 x (p = 0.000) and ADC Value ≥ 1200 3.7 x (p = 0.027).

CONCLUSION

MRI features associated with a higher diagnostic likelihood of DON include significant AC and elevated ADC values. ADC may show reasonable promise in diagnosing and predicting DON.

Comprehensive Comparisons of Different Treatments for Active Graves Orbitopathy: A Systematic Review and Bayesian Model-Based Network Meta-Analysis

CONTEXT

Graves orbitopathy is a specialized immunoinflammatory disorder related to abnormal thyroid function. Due to the complexity of the disease and its propensity to reoccur, targeted treatment is essential to improve the symptoms.

OBJECTIVE

This study aims to assess the efficacy and safety of various treatments for active thyroid eye disease.

METHODS

We conducted a comprehensive search for randomized controlled trials (RCTs), and ongoing RCTs registered on Controlled Trials, targeting treatments for thyroid eye disease until November 20, 2024. Employing a Bayesian framework, this network meta-analysis calculated risk ratios (RRs) or mean differences (MDs) with 95% CIs to size the effects for the predetermined outcomes. The study is registered with PROSPERO (CRD42024548030).

OUTCOME

The primary outcomes evaluated were overall response rate, clinical activity score (CAS), proptosis, diplopia, and adverse events.

RESULTS

For the overall response rate, teprotumumab (RR 5.5, 95% CI 2.3 to 16), mycophenolate combined intravenous glucocorticosteroids (IVGCs) demonstrated effectiveness over no treatment, ranked from most to least effective. Notably, teprotumumab showed the highest efficacy in reducing CAS (MD -1.57, 95% CI -3.81 to 0.68) and proptosis (MD -2.29, 95% CI -2.73 to -1.86). For diplopia improvement, teprotumumab and IVGCs were effective compared with no treatment.

CONCLUSION

Teprotumumab emerges as potentially the most effective treatment for reducing inflammation and increasing overall response rates when compared with no treatment; oral mycophenolate combined with IVGCs appears to be the best for improving proptosis. While some treatments raise safety concerns due to reported adverse events, oral methotrexate combined with IVGCs appear to offer a favorable balance between efficacy and safety among the evaluated treatments.

Soluble Immune Checkpoints Associated With Disease Activity and Treatment Response in GD and TED

CONTEXT

Soluble immune checkpoints play an important role in peripheral tolerance that has seldom been investigated in Graves' disease (GD) and thyroid eye disease (TED).

OBJECTIVE

The objective of this work is to examine the alteration of soluble immune checkpoints in GD and TED.

METHODS

We performed a quantitative multiplex analysis of 17 immune checkpoint proteins in serum from 50 GD patients without TED, 28 GD patients with TED, and 40 healthy controls. The association with demographic, serologic, clinical features and 27 cytokines was analyzed. A follow-up was conducted in GD patients without TED. Functional outcomes of sLAG-3 and sGITR were assessed in cell cultures using rh-LAG3, rh-GITR, an antagonistic LAG-3 antibody, and an antagonistic GITR antibody.

RESULTS

GD Patients with TED had distinct sICP and cytokine profiles compared with GD patients without TED. Active patients with TED exhibited elevation in the levels of sBTLA, sLAG-3, sGITR, sCD80, sCD86, and sPD-L1. Further, GD patients without TED with high sBTLA, sCD27, and sCD40 levels at baseline showed a better improvement in thyrotropin receptor antibody titers after antithyroid drug treatment. Adding recombinant human GITR and LAG-3 to peripheral blood mononuclear cell cultures resulted in increased inflammatory cytokine secretion and decreased anti-inflammatory cytokine secretion.

CONCLUSION

The present study uncovers disturbed soluble immune checkpoints and cytokines in GD patients with and without TED and may pave the way for novel immunological screening, allowing for identification of patients with TED at higher risk of developing active disease and patients with GD a better treatment response after antithyroid drug treatment.

Time to improvement following teprotumumab treatment of thyroid eye disease: real world experience

BACKGROUND

Teprotumumab is the only FDA-approved medication for thyroid eye disease (TED), showing benefits in reducing proptosis, diplopia, clinical activity score (CAS), and improving quality of life. This study describes the clinical outcomes of TED patients treated with Teprotumumab across 5 medical centers in Israel and evaluates time-to-improvement.

METHODS

A retrospective cohort study of electronic medical records for Israeli patients treated with Teprotumumab between 2021 and 2024 in five medical centers. The main outcome included changes in proptosis and diplopia.

RESULTS

Thirty-two TED patients (mean age 53.3, 19 females) received partial or complete treatment with Teprotumumab. All had previously failed IV glucocorticoids, and some also failed other biologics. Four patients had decompression surgery prior; 3 with optic neuropathy and 1 with proptosis improved after 1-7 doses. Proptosis decreased by 2.4mm (right) and 2.0mm (left) (p < 0.001, p = 0.002, paired sample t-test), with significant reductions in primary gaze diplopia (p = 0.015, chi-square test). Four patients (12.5%) had symptom recurrence 8-12 months post-treatment; one improved with additional treatment. Thirteen patients (40.6%) had significant improvement within 3 infusions. Adverse events included myalgia (n = 4), hyperglycemia (n = 3), diarrhea (n = 3), and hearing issues (n = 4). One patient developed encephalopathy, successfully treated with plasmapheresis.

CONCLUSIONS

Teprotumumab was effective in reducing diplopia and proptosis among Israeli TED patients, with rapid improvement in nearly half of the cases. Further studies are warranted to confirm these findings in real-world settings.

The Association Between Long-Term Air Pollution Exposure and Risk of Thyroid Eye Disease: A Nationwide Cohort Study in Taiwan

PURPOSE

Thyroid eye disease (TED) is a significant orbital disorder commonly associated with Graves' disease, characterized by retrobulbar tissue enlargement and various ocular symptoms. While the pathophysiology involves autoimmune processes, the potential influence of air pollution on TED remains unexplored. This study aims to investigate the association between long-term air pollution exposure and the risk of TED in Taiwanese adults with thyroid disease.

METHODS

A nationwide cohort study was conducted utilizing data from Taiwan's National Health Insurance Research Database. Adult patients newly diagnosed with thyroid disease between 2003 and 2013 were included. Exposure to 10 air pollutants over a decade was assessed and linked to patients' residential locations. Cox regression models were used to analyze the dose-response relationship between air pollutants and TED risk, adjusting for confounders.

RESULTS

The final cohort comprised 7340 patients, among whom 218 developed TED. Significant associations were observed between long-term exposure to 10 air pollutants and increased TED risk. A 1 standard deviation increase in the 10-year average exposure to sulfur dioxide, CO, particles less than 10 µm in diameter, particles less than 2.5 µm in diameter, nitrogen oxides, nitrogen monoxide, nitrogen dioxide, total hydrocarbons, nonmethane hydrocarbons, and methane corresponded to elevated TED risk of 26%, 62%, 74%, 49%, 47%, 32%, 56%, 27%, 20%, and 24%.

CONCLUSIONS

This study provides the first evidence linking long-term air pollution exposure to increased TED risk in individuals with thyroid disease. The findings underscore the importance of addressing air pollution as a modifiable risk factor for TED and advocate for the implementation of strategies to mitigate air pollution's adverse health effects. Further research is warranted to elucidate the underlying mechanisms and inform targeted interventions for TED prevention and management.

Thyroid-related orbitopathy: clinical overview, novel medical treatments and the role of orbital surgery

PURPOSE

The aim of our review is to report the thyroid orbitopathy treatments, focusing on novel medicines and ongoing research.

DESIGN

Review developed by a research group at Catholic University of the Sacred Heart.

METHODS

Overview of the literature synthesizing the findings of literature retrieved from searches of computerized databases, hand searches and authoritative texts. Although minimally invasive surgical techniques have been developed, current research is placing greater emphasis on the use of biological and immunosuppressive drugs for the treatment of thyroid eye disease (TED). Teprotumumab, a monoclonal antibody targeting the insulin-like growth factor-1 receptor, has just been approved by the Food and Drug Administration as a therapy for the treatment of TED. This approval is based on its ability to relieve both the clinical signs and symptoms of the condition, such as proptosis and diplopia. Synthetic peptides imitating T cell epitopes and TSHR-CAR-T cells represent a potential and novel immunotherapeutic strategy.

CONCLUSIONS

The growth of several novel therapies highlights the intricate nature of the disease's aetiology and the multitude of processes involved in its regulation. These advancements reveal a future direction focused on personalized treatment of Graves' orbitopathy. The integration of multiple disciplines is becoming increasingly indispensable in the management of patients with this disease.

Thyroid eye disease (Graves' orbitopathy): clinical presentation, epidemiology, pathogenesis, and management

Thyroid eye disease (TED; also known as Graves' orbitopathy), causes swollen extraocular muscles and orbital fat. Mechanistically, TED involves lid retraction, oedema and redness of the eyelids and conjunctiva, proptosis, diplopia, and optic neuropathy. Investigation of TED involves assessment of disease activity (inflammation) and disease severity. TED is predominantly mild in 77% of cases, moderate-to-severe in 22%, and rarely sight-threatening in 1% of patients. While most patients with TED have Graves' hyperthyroidism, up to 5% are euthyroid or even hypothyroid. Risk factors include male sex, older age, smoking, diabetes, hypercholesterolaemia, duration of hyperthyroidism, radioactive iodine therapy, and the presence of thyrotropin receptor (TSHR) antibodies (detectable in more than 95% of patients and directly related to TED activity and severity). Genetic immunisation of mice with TSHR, but not with insulin-like growth factor-1 receptor (IGF-1R), provides a reliable animal model of TED, demonstrating that TSHR is the primary autoantigen in the disease. Crosstalk between TSHR and IGF-1R occurs via a β-arrestin scaffold. Teprotumumab, a human monoclonal antibody that blocks IGF-1R without binding to TSHR, has been shown to significantly improve outcomes in moderate-to-severe TED, including greater proptosis reduction compared with intravenous methylprednisolone. However, its disadvantages include side effects (eg, hearing loss in 30% of patients), a high cost, and a high relapse rate. Therefore, intravenous steroids remain the treatment of choice in many parts of the world. Tocilizumab, which blocks the interleukin-6 receptor, is an effective treatment option for patients with TED who are steroid-resistant. This Review further discusses alternative medications, surgical treatments, local measures, and the importance of quality-of-life assessments and multidisciplinary care.

Long-Term Impact of Thyroid Eye Disease on Quality of Life: Insights From a Retrospective Cohort Study

OBJECTIVES

Thyroid eye disease (TED) seriously affects patients' quality of life (QoL), even if the disease is stable and nonactive. Data on clinical factors negatively influencing the QoL of patients with TED and long-term outcomes are limited. This study aims to evaluate the lasting impact of TED on QoL, focusing on the effects of previous TED treatments and identifying factors influencing long-term outcomes.

METHODS

A retrospective cohort study included 151 patients treated for active, moderate-to-severe and severe TED, with a mean follow-up of 8 years.

RESULTS

Higher clinical activity scores at diagnosis correlated with lower QoL scores. Thyroidectomy before immunosuppressive treatment was associated with lower QoL and an increased likelihood of orbital decompression. Any disease progression necessitating second-line treatments also negatively affected QoL. A decrease in thyrotropin receptor antibodies during active treatment and early treatment initiation positively affected visual functioning. Time-dependent regression analysis demonstrated no significant trend in QoL changes over time.

CONCLUSION

Our data reveal that disease severity, the timing of interventions and disease progression contribute to less favorable long-term QoL outcomes, extending years beyond active treatment. Early and accurate diagnosis and appropriate treatment can minimize poor long-term QoL in patients with TED.

Autoimmune neuro-ophthalmic disorders: pathophysiologic mechanisms and targeted biologic therapies

INTRODUCTION

Autoimmune neuro-ophthalmic disorders encompass a diverse array of conditions, including thyroid eye disease (TED), myasthenia gravis (MG), optic neuropathy due to giant cell arteritis (GCA), and optic neuritis related to multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). While traditional treatments have shown efficacy in managing symptoms, the rapid emergence of biologic therapies has brought forth new avenues for targeted intervention, revolutionizing treatment approaches for these conditions.

AREAS COVERED

This review highlights the pathophysiologic pathways and FDA-approved biologic therapies utilized in the management of autoimmune neuro-ophthalmic disorders. We explore multiple therapeutic approaches for autoimmune neuro-ophthalmic disorders, including IGF-1 R antagonism, IL-6 inhibition, complement inhibition, FcRn targeting, B-cell depletion and T-cell modulation. Literature from clinical trials, observational studies, and meta-analyses through 2024 was evaluated to assess efficacy, safety, and long-term outcomes.

EXPERT OPINION

Biologic therapies represent a significant advancement in autoimmune neuro-ophthalmic disorders, offering targeted approaches with improved efficacy and safety profiles compared to traditional treatments. Ongoing developments in biomarker identification and delivery systems suggest an increasingly personalized approach to treatment. Future advances will likely focus on optimizing patient selection, reducing costs, improving accessibility, and developing novel therapeutic targets.

Compound C exerts a therapeutic effect on Graves' orbitopathy via AMPK‑independent pathways

Compound C is an adenosine monophosphate‑activated protein kinase (AMPK) inhibitor, which is also recognized as a broad‑spectrum kinase inhibitor with anti‑proliferative effects. The present study investigated the therapeutic effects of a high concentration of compound C on Graves' orbitopathy (GO) pathogenesis beyond the AMPK‑dependent pathway using human orbital fibroblasts. Orbital connective tissue was obtained from patients with GO and healthy controls, and primary orbital fibroblasts were cultured. The cells were then pretreated with a non‑cytotoxic concentration of compound C, and stimulated with either IL‑1β or TGF‑β. Pro‑inflammatory cytokine expression, profibrotic protein production and adipogenesis were evaluated using western blotting and Oil Red O staining. Adipocyte differentiation following knockdown of the hippocampal signaling pathway was also analyzed. Hyaluronan secretion was assessed using ELISA. Notably, treatment with a non‑cytotoxic concentration of compound C (10 µM) significantly suppressed AMPK and yes‑associated protein (YAP) phosphorylation in orbital fibroblasts. In addition, compound C suppressed IL‑1β‑induced pro‑inflammatory cytokine production and TGF‑β‑induced profibrotic protein production, as well as the phosphorylation of Akt, SMAD 1/2/3, and hyaluronan secretion. Similar to compound C treatment, silencing YAP and transcriptional co‑activator with PDZ‑binding motif, significantly attenuated adipogenesis as determined by Oil Red O quantification and the production of adipogenic markers. It may be hypothesized that a high concentration of compound C suppresses inflammation, fibrosis and adipogenesis in orbital fibroblasts through YAP inactivation, since YAP knockdown effectively reduced adipogenesis in GO orbital fibroblasts. Taken together, these findings suggested that compound C may exert its therapeutic effects through an AMPK‑independent mechanism, inhibiting inflammation, adipogenesis and fibrosis in orbital fibroblasts.

Canonical and Truncated Transglutaminase-2 Drive TGF-β1 Autocrine Loop to Induce Fibrosis in Graves' Orbitopathy

Purpose

To evaluate the role of transglutaminase 2 (TGM2) in fibroblasts of Graves' orbitopathy (GO) and explore its potential mechanisms in orbital fibrosis.

Methods

A key gene selection model for GO was established through bioinformatics and machine learning. Orbital fibroblasts (OFs) were cultured from orbital connective tissue samples. Subsequently, three-dimensional spheroid models were developed. Lentiviral transduction was used to establish TGM2 overexpression and knockdown models. Fibrosis levels were assessed using Western blot, PCR, and collagen contraction assays. TGM2 activity was evaluated by FITC-cadaverine staining and the colorimetric assay. The canonical and truncated TGM2 isoforms were selectively introduced to restore expression. TGF-β1 levels in cell culture supernatants were measured by ELISA.

Results

The results of bioinformatics and machine learning indicate that TGM2 is a key characteristic gene in GO. Knockdown of TGM2 markedly suppresses the expression of fibrosis-related genes and reduces the proliferation, migration, and adhesion capabilities of fibroblasts. TGF-β1 can upregulate TGM2 expression and induces the production of both the canonical and truncated TGM2 forms. Similar results were observed in GO tissues. Restoration of TGM2_V2 expression following knockdown can prevent the inhibitory effects on guanosine triphosphate (GTP). Additionally, TGM2 is involved in the autocrine loop of TGF-β1. TGM2 inhibitors significantly reverse the fibrotic response induced by TGF-β1 in OFs.

Conclusions

TGM2 is highly expressed in GO fibroblasts and plays a key role in the TGF-β1 autocrine feedback loop. TGF-β1 induces more truncated TGM2 variants that bypass GTP inhibition, exacerbating fibrosis. Inhibiting TGM2 activity significantly reduces fibrosis markers.

Efficacy and Safety of Teprotumumab in Thyroid Eye Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

Teprotumumab was approved by the US Food and Drug Administration (FDA) for treating Graves' orbitopathy in adults on January 21, 2020. This study evaluates its efficacy and safety in treating thyroid eye disease (TED).

METHODS

We reviewed studies on teprotumumab for TED treatment from PubMed, Web of Science, EMBASE, Cochrane library, and Clinical trials. gov up to January 1, 2024. Outcomes included proptosis response, diplopia, Clinical Activity Score (CAS) score, and adverse events (AEs).

RESULTS

Our analysis included 10 studies, 4 randomized controlled trials, and 6 observational studies. The randomized controlled trials involved 210 teprotumumab patients and 193 controls. Teprotumumab significantly improved proptosis response (relative risk [RR] 4.18, 2.72-6.43), diplopia regression (RR 2.29, 1.54-3.41), and CAS score (RR 3.09, 1.98-4.80) compared to placebo. A significant reduction in proptosis was observed (standardized mean difference -8.38, -9.25 - -7.52). The risk of AEs and serious AEs was higher with teprotumumab. The 6 observational studies included 211 patients, showing an 82% proptosis response rate, a -3.31 mm change in proptosis, a 0.58 diplopia improvement rate, and a 0.66 pooled effect size for CAS score. AE incidence was 0.78, and serious AEs were 0.31.

CONCLUSION

Teprotumumab effectively reduces proptosis, improves diplopia, and lowers disease activity in TED, regardless of previous treatments, severity, or dosage, albeit with increased AEs. It has the potential to become a vital first-line treatment for TED, enhancing patient quality of life.

Radiation Therapy for Graves' Ophthalmopathy: When Is the Optimal Timing of Treatment and Evaluation

PURPOSE

Despite the decades of using radiation therapy (RT) for Graves' ophthalmopathy, the effects and optimal timing remain unclear. We retrospectively analyzed to evaluate the overall efficacy and response, predictive factors, and the effective timing of RT by assessing steroid requirement after RT in patients without prior surgery.

METHODS AND MATERIALS

Between 2008 and 2022, we analyzed 74 patients with Graves' ophthalmopathy who received RT to both orbits. Concurrent steroid therapy was administered to 51 patients. Symptoms were evaluated using a modified clinical activity score (CAS), defining responders as those with a ≥2 score improvement in CAS, diplopia, or a significant reduction in exophthalmos asymmetry. Common symptoms included eye swelling (81.1%), and conjunctival edema (81.1%). Diplopia observed in 48 patients (64.9%).

RESULTS

Median follow-up was 44.5 months (range, 4.8-169.6). CAS significantly improved in the early-immediate phase, 1 month after RT (P < .001). However, diplopia showed significant improvement at a relatively late phase, 4 months after RT (P = .039). Patients treated with steroids concurrently showed a faster response compared to those without steroids. Initiating RT within 12 months of symptom onset resulted in a shorter duration of steroid use after RT compared with later initiation (65 vs 286 days, P = .011).

CONCLUSIONS

Our study suggests an evaluation period of at least 4 months after RT regardless of concurrent steroid treatment, recognizing the prolonged improvement timeline for diplopia. Additionally, for reducing steroid use after RT, our study suggests optimal timing of RT within 12 months of symptom onset.

Efficacy, Safety, and Recurrence in Older Thyroid Eye Disease Patients Undergoing Teprotumumab Treatment

Increasing life expectancy and an aging population have preserved quality of life decisions into older adulthood, defined by some clinical standards as greater than 75 years of age. While teprotumumab may represent a breakthrough in the treatment of thyroid eye disease, the teprotumumab phase III trial included only 2 patients aged over 75. Four female patients between the ages of 78 and 86-of whom 3 completed 8 infusions and 1 completed 7 infusions before discontinuation-were included in the authors' study with a mean initial Clinical Activity Score score of 5.5, subjective diplopia, and proptosis. All patients experienced reduction in Clinical Activity Score with teprotumumab treatment. Two patients were subjective diplopia responders. Of the 6 eyes with collected measurements, all demonstrated a ≥2 mm reduction in post-treatment Hertel measurements. Most common adverse events were hyperglycemia, dysgeusia, fatigue, and alopecia. One patient with diabetes experienced an A1C rise requiring insulin. One patient had recurrence with increasing proptosis and recurrence of diplopia.

Efficacy and safety of Tocilizumab for thyroid eye disease: a systemic review and Meta-analysis

PURPOSE

This study aims to investigate efficacy and safety of TCZ in TED.

METHODS

Performing a meta-analysis of included studies. PubMed, Web of Science, Embase, Cochrane Library, and Clinicatrials.gov databases were retrieved to identify all related published literatures as of May 2024. When I2 > 50%, the random effect model was used; otherwise, the fixed model was used.

RESULTS

This meta-analysis included 413 patients with TED. Therapeutic effect of TCZ was evaluated by various metrics, including clinical activity score (CAS), response rate, inactivation rate, proptosis, visual acuity (VA), TRAB/TSI levels, diplopia, eye motility, intraocular pressure (IOP), and relapse rate. The final analysis revealed that TCZ significantly reduced CAS (-4.47, 95%CI [-5.14, -3.79]), with high response rate (0.93, 95%CI [0.88, 0.97]) and inactivation rate (0.90, 95%CI [0.83, 0.96]). Significant improvements were also observed in proptosis (2.05 mm reduction, 95%CI [-2.42, -1.67]) and diplopia (0.56 improvement rate, 95% CI [0.40, 0.72]). Regarding safety, the pooled incidence of adverse events (AEs) was 0.31(95%CI [0.15, 0.48]). Hyperlipidemia was the most prevalent AE, followed by neutropenia and infection. Furthermore, subgroup analysis demonstrated TCZ's superior performance in terms of inactivation rate, antibody decline rate, relapse rate, and safety.

CONCLUSIONS

According to the best available evidence, TCZ appears to be an acceptable alternative for moderate to severe TED patients due to its significant efficacy, well-tolerability, and low relapse rate. Larger sample size and controlled studies are warranted to promote the position of TCZ in TED treatment.

Bibliometric Analysis of Orbital Surgery Using Web of Science Database

AIM

There are more than 100 different clinical pathologies that affect the orbit, originating from the orbit or surrounding structures. Various surgical approaches have been described to solve this number of lesions. To date, there have been few evaluations of research productivity in the field of orbital surgery. The aim of this study is to analyze the research productivity of articles on orbital surgery.

METHODS

On October 20, 2024, using the advanced search section in the Web of Science (WoS) Core Collection database, a search was made about orbital surgery. From 1980 to November 20, 2024, research articles in the relevant field were analyzed. Language restrictions are not used. The filter was "Topic=Orbital Surgery OR Orbit Surgery OR Oculoplastic OR Oculoplastics OR Oculoplasty OR Orbitotomy OR Orbital Tumor Surgery OR Optic Nerve Surgery OR Orbital Decompression OR Orbital Reconstruction OR Orbital Exenteration OR Orbital Implant Surgery (Should - Search within topic)." Filters were applied, and as a result, 4590 publications were included in this study. VOSviewer software was used to perform bibliometric analyses.

RESULTS

The number of publications and citations for each year mostly increases until 2021. Among the countries with the most documents and citations, the United States ranks first in both rankings. Also, the organization with the most publications is the University of California, Los Angeles. Ophthalmic Plastic and Reconstructive Surgery is the journal that publishes the most documents and receives the most citations. The most cited 3 document is about Graves orbitopathy. The most recurring keywords were related to treatment and disease management.

CONCLUSIONS

This study would provide a novel perspective to the studies about orbital surgery and contribute to the researchers about the limits of the topic, and being aware of the active journals that publish the papers on this issue would facilitate the work of the researchers.

The burden of illness in thyroid eye disease: current state of the evidence

Introduction

Thyroid eye disease (TED) is a disabling autoimmune condition characterized by proptosis and progressive orbital inflammation involving the extraocular muscles, orbital fat, and connective tissues. Clinical features include facial disfigurement, diplopia, dry eyes, and in severe cases, vision loss. Consequently, individuals with TED suffer significant physical and psychological burdens that impact their quality of life. Currently, there is no standardized definition or International Classification of Diseases code for TED, and the disease landscape remains incompletely understood; moreover, TED diagnostic criteria and treatment recommendations have not been thoroughly assessed across diverse populations. It is necessary to better understand the clinical, humanistic, and economic burden of TED and identify gaps in our knowledge to improve TED management and outcomes.

Methods

To describe the current understanding of TED epidemiology, diagnosis, disease burden, and recent TED treatment guidelines, a targeted literature review was conducted, searching multiple databases using key words of specific search topics (i.e., TED; epidemiology, humanistic, economic, and clinical burden; treatment; and practice guidelines) for articles published between October 2013 and October 2023 in the United States, United Kingdom, and Europe (France, Germany, Italy, and Spain). Articles published between May 2014 and May 2024 describing diverse racial and sociodemographic presentations of TED were included.

Results

TED is a complex disease with an array of risk factors, including thyroid dysfunction, thyroid-stimulating immunoglobin, smoking, and comorbid conditions. The natural history of TED is not clearly defined, and diagnosis is complicated due to the array of phenotypes and orbital symptoms observed. Although novel first-line treatments are available in select countries, there is an unmet need for improved treatments for moderate-to-severe and sight-threatening TED. Individuals with TED continue to experience poor health-related quality of life due to the clinical burden that TED imposes along with large healthcare resource utilization costs and treatment costs, and economic evaluation studies are limited. Importantly, there is still a need for studies that explore diverse populations and the impact of race and ethnicity on the disease landscape.

Conclusion

TED remains an incompletely characterized disease with major knowledge gaps, particularly among historically underserved populations.

"Real Life" Utility of the Graves' Ophthalmopathy-Quality of Life in a Multidisciplinary Thyroid Eye Disease Service

PURPOSE

This study aimed to describe the correlation of demographic and clinical factors with the Graves' ophthalmopathy-quality of life (GO-QOL) visual function (VF) and appearance (A) scores in a cohort attending a metropolitan multidisciplinary thyroid eye disease (TED) service.

METHODS

This is a cross-sectional retrospective study of 152 consecutive TED patients who completed the GO-QOL questionnaire. Clinical parameters, including endocrine diagnosis and status, TED activity and severity, Gorman diplopia score, and TED treatments were recorded at the time of completing each questionnaire and retrospectively analyzed.

RESULTS

A total of 257 GO-QOL questionnaires were completed over 32 months, with 59 patients providing sequential responses. The mean age was 50.0 ± 13.1 years, 77.0% (117/152) were female and 52.0% (79/152) were Caucasian. Graves' disease was present in 86.2% (131/152) of participants, and 91.4% (139/152) were euthyroid at the time of the questionnaire. The mean time since TED onset was 2.5 years (range: 0.25-180 months). The mean ± standard deviation GO-QOL scores in the mild, moderate-to-severe, and sight-threatening disease cohorts for VF were 92.2 ± 15.2, 70.9 ± 28.6, and 56.6 ± 29.6, respectively, and for A were 79.1 ± 22.3, 48.2 ± 29.7, and 66.1 ± 35.3, respectively. VF and A scores were inversely correlated with clinical activity scores. Both scores improved postimmunosuppression but only A scores improved following decompression and rehabilitation surgery. Females and younger patients had lower A but not VF scores. East Asians and Caucasians had higher VF and A scores than African-Caribbeans.

CONCLUSION

The GO-QOL's granularity highlights the diverse functional and psychosocial experiences of TED patients, underscoring the need to integrate this valuable but underutilized tool into routine clinical practice.

The role of IL-6 in thyroid eye disease: an update on emerging treatments

Elevated serum interleukin-6 (IL-6) levels have been shown to correlate with disease activity in patients with thyroid eye disease (TED), a complex, heterogeneous, autoimmune disease affecting thousands of people worldwide. IL-6 plays a pivotal role in the pathogenesis of TED through three key mechanisms that together may contribute to inflammation, tissue expansion, remodeling, and fibrosis within the orbit. First, IL-6 drives an autoimmune response targeting the thyroid-stimulating hormone receptor (TSHR) by promoting the production of autoantibodies (i.e. TSHR-Ab, TSI), thereby triggering TSHR-dependent immune pathways. Second, IL-6 stimulates the activation and differentiation of orbital fibroblasts, which contributes to the inflammatory process and increase adipogenesis. Finally, IL-6 stimulates T-cell-mediated inflammation, amplifying the immune response within orbital tissues. Although corticosteroids and surgery have served as mainstays of TED treatment, a multimodal approach is often required due to the disease's heterogeneous presentation and response to current treatment options. TED is a chronic, lifelong condition characterized by periods of exacerbation and remission, with inflammation playing a central role in disease progression and severity. Because inflammation can flare intermittently throughout a patient's life, there is growing interest in targeting specific components of the immune system to reduce disease activity and severity. This review focuses on the current evidence supporting IL-6 as a key mediator of TED pathogenesis and explores its potential as a diagnostic biomarker and therapeutic target of the disease.

Negative association between serum calcium and glucocorticoid-induced hypertension in thyroid-associated ophthalmopathy patients treated with methylprednisolone

Background

Hypertension is a common adverse event after systemic glucocorticoid therapy. Previous studies have suggested that blood pressure (BP) regulation is related to serum calcium. However, whether serum calcium affects the risk of glucocorticoid-induced hypertension remains understudied.

Methods

We used data from thyroid-associated ophthalmopathy (TAO) patients who completed a course of intravenous methylprednisolone (IVMP). Patients with high BP at baseline, a history of hypertension, and missing data were excluded. Glucocorticoid-induced hypertension was defined as systolic BP (SBP) ≥ 140 mmHg or diastolic BP (DBP) ≥ 90 mmHg during follow-up. Multivariate logistic regression and generalized additive models were used to investigate the associations between serum calcium and glucocorticoid-induced hypertension. Bar charts were used to compare the SBP and DBP fluctuations between patients with and without hypocalcemia. After accounting for missing data, all analyses were repeated in the imputed cohort.

Results

Serum calcium was negatively correlated with glucocorticoid-induced hypertension after adjusting for covariates with p-value < 0.1 (including age, body mass index, SBP, and DBP). For each 0.1 mmol/L increase in serum calcium, the OR (95% CI) was 0.61 (0.39, 0.95). Furthermore, a nonlinear relationship was observed, with an inflection point at 2.10 mmol/L. After the serum calcium level was converted into a categorical variable, hypocalcemia was positively associated with glucocorticoid-induced hypertension (OR = 3.26, 95% CI = 1.11-9.53). Patients with hypocalcemia exhibited significantly greater SBP fluctuations than patients without hypocalcemia (p < 0.05). These results were stable when adjusting for confounders and in the analyses of the imputed cohort.

Conclusions

Hypocalcemia was associated with glucocorticoid-induced hypertension in TAO patients. Further research is needed to confirm these findings in larger populations and to investigate whether calcium supplementation before glucocorticoid therapy may reduce such risk.

The CD163 + tissue-infiltrating macrophages regulate ferroptosis in thyroid-associated ophthalmopathy orbital fibroblasts via the TGF-β/Smad2/3 signaling pathway

BACKGROUND

Thyroid-associated ophthalmopathy (TAO) is a thyroid function-related, organ-specific autoimmune disease that primarily leads to specific reactive changes and tissue remodeling in the periocular region. The exact pathogenesis of TAO remains unclear.

METHODS

High-throughput gene expression datasets related to TAO were comprehensively retrieved from the Gene Expression Omnibus (GEO) database, selecting GSE174139 and GSE158464 for analysis. Differentially expressed genes (DEGs) between TAO patients and healthy controls were identified, and ferroptosis-related genes (FRGs) were obtained from the FerrDb database. The intersection of DEGs and FRGs yielded ferroptosis-related genes associated with TAO.The transcriptional expression of FRGs was validated using real-time quantitative polymerase chain reaction (RT-qPCR) on orbital adipose tissue samples from TAO patients and healthy controls. Single-cell sequencing of six human tissue samples further analyzed changes in cellular subpopulations within the TAO microenvironment.Additionally, a co-culture model of CD163 + macrophages and TAO orbital fibroblasts, along with an in vitro TGF-β1-induced orbital fibroblast (OF) model, was constructed to validate the role of the TGF-β1/SMAD2/3 axis in ferroptosis regulation. Finally, potential clinical drugs targeting CD163 + macrophages with high ferroptosis activity in TAO were predicted using the Random Walk with Restart (RWR) algorithm combined with the DGIdb database.

RESULTS

We first utilized TAO-related datasets from the GEO database, combined with the FerrDb ferroptosis database, to identify changes in iron metabolism genes during TAO progression through differential expression analysis, screening 7 key ferroptosis-related proteins. In vitro validation revealed that all but AOPQ and LGMN, which were upregulated, exhibited downregulated expression.Single-cell sequencing of orbital connective tissue from 4 TAO patients and 2 healthy controls identified 16,364 cells spanning 18 cell types. Analysis of the 7 key ferroptosis-related proteins revealed that fibroblasts and macrophages displayed elevated ferroptosis signaling during TAO progression. Subcluster analysis of macrophages identified 4 distinct subpopulations, with the C2 subpopulation-characterized by high expression of CD163 and CCL18-exhibiting prominent ferroptosis activation signals.Further validation using clinical tissue samples, a co-culture model of CD163 + macrophages and TAO orbital fibroblasts, and an in vitro TGF-β1-induced orbital fibroblast (OF) model confirmed aberrant activation of the TGF-β1/SMAD2/3 pathway as a key regulator of ferroptosis. Hub gene analysis of C2 subpopulation marker genes, combined with the DGIdb database, predicted potential clinical drugs targeting the C2 macrophages.

CONCLUSION

This study, integrating single-cell RNA-Seq and bulk transcriptome analysis, revealed the involvement of CD163 + tissue-infiltrating macrophages in regulating ferroptosis of orbital fibroblasts during TAO progression and identified therapeutic candidates targeting macrophage ferroptosis signaling in TAO. Furthermore, in vitro experiments demonstrated that activation of the TGF-β1/SMAD2/3 axis promotes ferroptosis in TAO orbital fibroblasts, highlighting a novel pathway for potential therapeutic intervention.

A novel indicator in evaluating endoscopic orbital decompression for thyroid-associated orbitopathy

Objective

To introduce the increase rate of effective orbital volume (IREOV) as a novel indicator for evaluating outcomes of endoscopic orbital decompression in thyroid-associated orbitopathy (TAO).

Methods

In this retrospective study, 69 subjects (124 orbits) underwent either medial wall decompression (MWD) or lateral wall decompression (LWD) combined with fat decompression for TAO. Artificial intelligence was used to segment the orbit and calculate IREOV to compare MWD and LWD effectiveness. The impact of postoperative extraocular muscle expansion on IREOV was also assessed, with patients categorized into muscle hypertrophy and fat hyperplasia groups.

Results

Using Artificial Intelligence OrbitNet system, the average IREOV was 0.14 ± 0.08. Postoperative IREOV was significantly higher for MWD (0.17 ± 0.07) than for LWD (0.05 ± 0.05) (P<0.001). Medial rectus muscle expansion had the greatest impact on IREOV after MWD, while lateral rectus muscle expansion affected IREOV after LWD. Most importantly, TAO patients with muscle hypertrophy exhibited higher IREOV after MWD compared to those with fat hypertrophy (P<0.001). Proptosis reduction was 3.20 ± 1.37mm for MWD and 3.02 ± 0.68mm for LWD, with no significant difference (P>0.05).

Conclusion

Accurate IREOV calculation through artificial intelligence is crucial for evaluating the efficacy of orbital decompression surgery. For TAO patients presenting with fat hyperplasia, LWD should be prioritized to minimize the risk of postoperative extraocular muscle expansion. In cases where MWD is performed on fat hyperplasia patients, rigorous postoperative surveillance for extraocular muscle expansion is essential.

Optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) for assessing thyroid-associated ophthalmopathy activity

PURPOSE

To explore the role of retinal and choroidal parameters obtained via optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) in predicting thyroid-associated ophthalmopathy (TAO) activity, providing a scientific basis for improved clinical diagnosis and treatment.

METHOD

This study included 90 active TAO patients (178 eyes), 69 inactive TAO patients (138 eyes), and 66 healthy individuals (132 eyes). It compared choroidal and retinal parameters and magnetic resonance imaging structural differences, analyzed correlations between these parameters, and developed a predictive model for TAO activity.

RESULTS

Compared to control and inactive groups, active group had thicker subfoveal choroidal thickness (SFCT) and reduced luminal area, stromal area, and total choroidal area. Active group showed reduced vessel density in the foveal and nasal regions versus inactive group, and in the foveal, superior, and nasal regions versus controls. Foveal avascular zone (FAZ) area was larger in active group than in both control and inactive groups. Active group also had larger inner diameters and signal intensity ratio (SIR) of the extraocular muscles than inactive group. SFCT correlated with proptosis, and FAZ correlated with proptosis, maximum extraocular muscle diameter, and SIR. The multivariate model achieved area under the curve values of 0.836 in overall TAO population and 0.855 in hyperlipidemia subgroup, outperforming the univariate model.

CONCLUSION

Retinal and choroidal parameters, obtained via OCT/OCTA, are keys to developing TAO activity predictive models, with enhanced accuracy in TAO patients with hyperlipidemia.

Emperor Leo I "the Thracian": a possible case of Graves' orbitopathy

Representation of exophthalmos in ancient artworks is reported by several authors. In the present paper we analyze a sculpture belonging to the V century AD, likely embodying the eastern Roman emperor Leo I. As the portrait statue is sculpted with uncommon prominent eyes, we discuss the possibility that the historical personage was affected by exophthalmos due to Graves' orbitopathy.

Corneal breakdown in thyroid eye disease: Presentation and outcomes over a decade

PURPOSE

Corneal breakdown in thyroid eye disease (TED) is an ocular emergency. This study aimed to assess the outcome of multimodal management for corneal breakdown in TED.

METHODS

This retrospective audit included all consecutive corneal breakdowns in TED patients between November 2011 and May 2023. The primary outcome measure was the best corrected visual acuity (BCVA), and secondary outcome measures included proptosis, clinical activity score (CAS), and proportion of globe salvage.

RESULTS

In all, 35 TED patients (50 eyes; 15 bilateral) were included in this study. The mean age was 50.6 + 16 years (range 17-83), and 23 were male. Median TED duration was 5 months (range 1-108). Seven patients (nine eyes) developed corneal breakdown ≥2 years after disease onset. Corneal breakdown was graded as superficial punctate keratopathy in 18, microbial keratitis in 14, and microbial keratitis with thinning and/or perforation in 18 eyes. At median follow-up of 17 months (range 2-72), in the orbital decompression group, overall mean BCVA before and after orbital decompression showed improvement from 1.2 to 0.7, mean proptosis from 25.4 ± 3.5 to 20.7 ± 2.1 mm, and median CAS from 4.2 ± 1.3 to 0.3 ± 0.6. In the medical management group, the mean BCVA changed from 1.7 to 1.5, mean proptosis from 22.5 ± 2.5 to 22.3 ± 2.4 mm, and CAS from 3.0 ± 1.4 to 1.1 ± 1.4 before and after treatment, respectively. At the final follow-up, 44 eyes (88%) achieved globe salvage, while six eyes were eviscerated.

CONCLUSION

Corneal breakdown necessitates expeditious and intensive multimodal management - topical medications, systemic medications, eyelid surgery, and orbital decompression surgery. In severe corneal breakdown with microbial keratitis with thinning and perforation, multimodal management helps achieve a high percentage of vision and globe salvage.

Specific molecular imaging of BALB/c model mice with Graves' ophthalmopathy based on high expression of insulin-like growth factor 1 receptor

OBJECTIVE

At present, most of the targeted imaging based on insulin-like growth factor 1 receptor (IGF-1R) is for tumor research, and there is no IGF-1R-targeted imaging for Graves' ophthalmopathy(GO). This study aims to develop a peptide probe, 99mTc-ZIGF1R:4551-GGGC, targeting the IGF-1R, and to achieve specific imaging in Graves' disease (GD) animal models exhibiting GO.

METHODS

99mTc-ZIGF1R:4551-GGGC probe was synthesized using a direct labeling method and its labeling efficiency assessed via instant thin-layer chromatography (ITLC). Western blot analysis confirmed the overexpression of IGF-1R in malignant melanoma B16F10 cells. Subsequent SPECT/CT whole-body imaging of B16F10 tumor-bearing mice evaluated the probe's targeting accuracy. In addition, a GO model was established using an electroporation immunoassay, followed by serological and histopathological examinations. The GO models then underwent 99mTc-ZIGF1R:4551-GGGC SPECT/CT imaging to assess eye-targeted imaging capabilities.

RESULTS

The peptide probe exhibited a labeling efficiency exceeding 90%. Both GD and GO models were effectively created via electroporation immunoassay. Imaging results indicated significant accumulation and retention of the peptide probes in the tumors of B16F10 tumor-bearing mice. In the GO models, probe uptake was predominantly observed in retrobulbar tissues, contrasting with primary accumulation in the lungs and gastrointestinal tract in normal mice, where only minimal tracer was observed in retrobulbar tissues. Notably, GO mice demonstrated higher probe uptake and prolonged retention.

CONCLUSION

This study successfully established GD and GO models, reducing the duration of the immune cycle. Moreover, a peptide probe targeting IGF-1R was synthesized, enabling specific imaging of retrobulbar tissues in GO models.

Factors Associated with Response to Intravenous Glucocorticoids in Active Moderate-to-Severe Thyroid Eye Disease

Background: Intravenous glucocorticoids (IVGCs) are the first-line treatment for active moderate-to-severe thyroid eye disease (TED) in many countries worldwide, mainly because of their anti-inflammatory efficacy. Methods: Retrospective cohort study of 64 patients with active moderate-to-severe TED, without dysthyroid optic neuropathy, treated between 2003 and 2023 at a single tertiary centre with the 12 weeks IVGC EUGOGO (European Group on Graves Orbitopathy) protocol. All patients were evaluated for response to IVGC according to the clinical judgment (CL) and 44/64 (69%) patients were also evaluated with the EUGOGO 2021 revised composite index (CI). Results: The mean patients' age at IVGC initiation was 51.7 ± 11 years, 47/64 (73.5%) were women, 56/64 (87.5%) were Caucasians, and 33/64 (51.5%) were active smokers. At 6 months after IVGC, 48 out of 64 (75%) patients evaluated with CL and 32 out of 44 (73%) patients evaluated with EUGOGO CI responded to the treatment. Nonresponders tended to be older than responders (56.6 ± 10.2 vs. 50.1 ± 10.8 years, p = 0.040 for CL and 56.5 ± 11.9 vs. 50.3 ± 11.6 years, p = 0.131 for EUGOGO CI) and had higher clinical activity score (CAS) before IVGC (5.0 ± 1.1 vs.4.2 ± 1.1, p = 0.022 for CL and 4.7 ± 0.6 vs. 3.1 ± 0.8, p < 0.001 for EUGOGO CI). In patients evaluated with CL or EUGOGO CI, respectively, multivariable logistic regression identified age at IVGC initiation (odds ratio [OR] = 0.92 [95% confidence interval (CI) 0.86-0.99], p = 0.024 and OR = 0.88 [CI 0.77-0.99], p = 0.046) and CAS before IVGC (OR = 0.53 [CI 0.31-0.90], p = 0.021 and OR= 0.08 [CI 0.01-0.38], p = 0.001) but not active smoking as independent factors associated with response to IVGC. The optimal cut-off associated with poorer response to IVGC was CAS ≥4.5/7 (66.7% specificity, 56.3% sensitivity; Area Under the Curve [AUC] = 0.689 [CI 0.54-0.83], p = 0.010) in patients evaluated with CL and CAS ≥3.5/5 (65.6% specificity, 91.7% sensitivity; AUC = 0.910 [CI 0.80-1.01], p < 0.001) in patients evaluated with EUGOGO CI. Conclusion: Older age and higher CAS before treatment were associated with poorer response to IVGC. Patients with these characteristics could be offered other immunotherapies as a first-line treatment for active moderate-to-severe TED.

Statins and Thyroid Eye Disease: A Propensity Score-Matched Retrospective Cohort Analysis

Background Thyroid eye disease is a sight-threatening disorder associated with Graves's disease. While treatment is aimed at stabilizing established thyroid eye disease, there are limited investigations regarding prevention. Statins, known for their anti-inflammatory properties, are one such treatment that has been investigated for thyroid eye disease. This study retrospectively analyzes the impact of statin medications on thyroid eye disease and related outcomes from real-world data using TriNetX Global Collaborative Network (TriNetX, Cambridge, MA, USA). Objective The primary objective of this study is to analyze the risk of developing thyroid eye disease in patients with Graves' disease treated with statin medications relative to those without exposure up to five years. Secondary objectives of this study include analyzing thyroid eye disease-related outcomes, including diplopia, optic nerve surgery, optic nerve injury, strabismus, blindness, requirement for teprotumumab, color vision deficiencies, and referral to ophthalmology. Methods Data were collated utilizing TriNetX Global Collaborative Network, a platform of globally de-identified patient information from over 140 healthcare organizations. Patients more than 18 years of age with a diagnosis of Graves' disease (ICD-10: E05.0 Thyrotoxicosis with Diffuse Goiter) were divided into Cohorts A (administration of statin medication following diagnosis of Graves' disease, n = 66,444) and B (no statin medication administration, n = 225,905). Via implementation of propensity score matching to control for confounding factors, a total of n = 43,025 matched patients per cohort was obtained. Hazard ratios (HRs) and 95% confidence intervals (CIs) were used to assess the primary and secondary objectives over a five-year follow-up period. The t-test was used for the calculation of mean averages of ophthalmology referrals and to determine statistical significance. Results Patients treated with statin medications (Cohort A) demonstrated a significantly lower HR for the development of exophthalmos (HR = 0.559, 95% CI 0.521-0.601, p < 0.001). Statin medications were furthermore associated with a reduced HR for diplopia (p < 0.001), optic nerve surgery (p = 0.018), and requirement for teprotumumab (p = 0.047). No significant reduction in hazards for color vision deficits, strabismus, optic nerve injury, or blindness was noted. Additionally, there was no significant difference in referrals to ophthalmology. Conclusion The findings from this study suggest that statin therapy may be protective against the development of thyroid eye disease and associated complications. Further randomized controlled trials are required to validate these findings and establish a therapeutic role for statins in thyroid eye disease.

Rituximab Treatment as Second-Line Therapy in Glucocorticoid Nonresponsive Graves' Orbitopathy: A Nonrandomized, Controlled, Interventional Study

OBJECTIVE

In moderate-to-severe Graves' orbitopathy, rituximab is recommended as second-line therapy in patients nonresponsive to intravenous glucocorticoids. We aimed to evaluate rituximab as early second-line therapy, as data are scarce and contradictory.

METHODS

In this nonrandomized, controlled, interventional study, patients with Graves' orbitopathy started on intravenous glucocorticoids. After 4 weeks, patients with < 2 points improvement in clinical activity score (CAS) were switched to rituximab [Non-Responders Rituximab (NR-RTX) group] and were compared to the remaining patients who continued with intravenous glucocorticoids for 12 weeks [Responders-Glucocorticoid (R-GC) group]. A retrospective group of non-responsive patients who were provided regular care with intravenous glucocorticoids for 12 weeks was used as control [Non-Responders-Regular Care group]. Background data and CAS were recorded for all groups at 0, 4, 12, 18, and 68 weeks. Quality of life (QoL) and safety data were collected from the NR-RTX and R-GC groups.

RESULTS

The NR-RTX group (n = 12) was similar to the others at baseline except for a 1-point lower median CAS compared to the NR-RC group (n = 12) (P = .03), and for having twice as many men compared to the R-GC group (n = 13) (P = .03). At 4 weeks, a linear mixed model indicated that the R-GC group had a 1.21-point (95% CI: -2.40 to -0.02) lower value for CAS compared to the NR-RTX group. CAS for all groups converged over time. Similar models for QoL revealed no treatment or time effects.

CONCLUSION

Switch to RTX early in the treatment course did not result in better CAS or QoL, compared to continuous intravenous glucocorticoids.

Evaluation of fibroinflammatory activity in thyroid eye disease using [18F]AlF-NOTA-FAPI-04 PET/CT: A prospective study

PURPOSE

This study evaluates the value of [18F]AlF-NOTA-FAPI-04PET/CT in assessing the disease activity of thyroid eye disease (TED).

METHODS

Twenty-three TED patients and ten healthy controls were prospectively recruited and underwent [18F]AlF-NOTA-FAPI-04 PET/CT scans. TED eyes were classified by Clinical Activity Score (CAS) as active (CAS +) or inactive (CAS-). PET analysis included qualitative and quantitative evaluations. Qualitative analysis categorized TED eyes as positive (FAPI +) or negative (FAPI-), while quantitative analysis including SUVmax and target-to-backgroud ratio (TBR) of each extraocular muscle (EOM). Pathological assessment of 16 EOM samples from 15 TED eyes was used as a gold standard to evaluate the diagnostic accuracy of CAS-driven and FAPI-driven assessments.

RESULTS

Eye-based analysis included 42 TED eyes and 20 control eyes. SUVmax did not differ significantly between CAS-/FAPI + (n = 8) and CAS + /FAPI + (n = 17) eyes; though both groups had significantly higher SUVmax than CAS-/FAPI- (n = 16), CAS + /FAPI- (n = 1), and control eyes (n = 20) (all P < .05). Diffuse high FAPI uptake with excellent TBR was observed in pathologically active EOMs and had higher SUVmax and TBR than inactive EOMs (SUVmax: 9.57 ± 2.79 vs. 4.04 ± 1.02, TBR: 2.99 ± 1.00 vs. 1.00 ± 0.35, both P < .001). An SUVmax cutoff value of 5.95 yielded an area under the receiver operating characteristic curve of 0.98 for predicting active disease. Sensitivity and specificity of CAS-driven and FAPI-driven assessments for TED activity were 72.7% and 100%, 100% and 100%, respectively. SUVmax positively correlated with pathological fibroinflammatory score (r = 0.68, P = .004).

CONCLUSION

The diffuse high FAPI uptake with excellent TBR in the EOMs could illustrate the activity of TED, positively correlated with pathological fibroinflammatory scores. These findings suggest that [18F]AlF-NOTA-FAPI-04 PET/CT may serve as a promising reliable non-invasive approach for assessing disease activity in TED, potentially superior to the CAS.

Clinical Impact of Radiotherapy in Steroid-Refractory Graves' Orbitopathy

BACKGROUND

Graves' orbitopathy (GO) is the most common extrathyroidal manifestation of Graves' disease. Treatment options depend on its severity. Orbital radiotherapy is recommended as a second-line treatment in patients who are refractory or intolerant of glucocorticoid treatment. This study aimed to analyze the clinical outcome after radiotherapy in patients diagnosed with Graves' orbitopathy who are refractory to glucocorticoids.

METHODS

We retrospectively analyzed the clinical data of 10 patients with Graves' orbitopathy who did not respond to glucocorticoid management. They were treated with retrobulbar radiotherapy between January 2010 and January 2021, with a schedule of 20 Gy in 10 fractions. The variables analyzed were ocular movements, exophthalmos, diplopia, retrobulbar pain, ectropion, visual acuity, eyelid closure, and conjunctival hyperemia.

RESULTS

Categorical variables were compared before and after radiotherapy treatment in the evaluated patients. A statistically significant response to radiotherapy was observed in the following outcomes: exophthalmos (p=0.005) and retrobulbar pain (p=0.04). One case of local recurrence was observed at 20 months of follow-up, achieving a local control of 90%. Recurrence-free survival (RFS) at one, three, and five years was 100%, 90%, and 90%, respectively.

CONCLUSIONS

Radiotherapy is an effective and well-tolerated treatment that reduces exophthalmos and retrobulbar pain and can prevent disease progression.

Quantitative Analysis of Orbital Soft Tissues Using Three-Dimensional Fast Spin Echo With 2-Point Dixon-Based Fat Suppression Sequence: Its Association With Methylprednisolone Pulse Therapy Treatment Efficacy in Thyroid-Associated Ophthalmopathy

BACKGROUND

Three-dimensional fast spin echo with 2-point Dixon-based fat suppression (3D-FSE-Dixon) sequence may assess volume and water fraction (WF) of orbit.

PURPOSE

To explore the association between 3D-FSE-Dixon based parameters and methylprednisolone pulse therapy (MPPT) efficacy in active moderate-to-severe thyroid-associated ophthalmopathy (TAO).

STUDY TYPE

Retrospective.

POPULATION

Fifty-nine TAO patients (29 females, 30 males, 49.1 ± 10.9 years) were included: 26 (15 females, 11 males, 48.4 ± 11.1 years) showed improvement and 33 (14 females, 19 males, 49.6 ± 10.9 years) did not.

FIELD STRENGTH/SEQUENCE

3D-FSE-Dixon sequence of orbits at 3 T.

ASSESSMENT

Manual segmentation delineated bony orbit (BO), whole orbit (WO), globe (GO), lacrimal gland (LG), and optic nerve (ON). Multi-dimensional threshold (MDT) identified orbital fat (OF). Extraocular muscles (ETM) were obtained by subtracting other tissues from WO. WF was calculated from water and in-phase images. Treatment efficacy, the clinical outcome, was assessed within 2 weeks after MPPT.

STATISTICAL TESTS

Unpaired t-test and Mann-Whitney U test compared normal and non-normal data, respectively. Paired t-test analyzed parameter changes pre- and post-MPPT. Multivariate logistic regression analysis identified factors independently associated with the efficacy of MPPT. Significance was set at P < 0.05.

RESULTS

Responsive group showed significantly higher pre-treatment WF (ETM, 0.86 ± 0.06 vs. 0.82 ± 0.07; OF, 0.21 ± 0.04 vs. 0.19 ± 0.02), with no difference in volume (OF: 21.34 ± 3.33 vs. 21.36 ± 3.46, P = 1.00; ETM: 13.48 ± 2.82 vs. 13.72 ± 3.45, P = 1.00) or volume ratio (OF/GO: 3.23 ± 0.50 vs. 3.26 ± 0.56, P = 1.00; ETM/GO: 2.06 ± 0.58 vs. 2.12 ± 0.64, P = 1.00). WF significantly decreased in responsive group (ETM, 0.86 ± 0.06 vs. 0.79 ± 0.05; OF, 0.21 ± 0.04 vs. 0.17 ± 0.03) but not decreased in unresponsive group (ETM, 0.81 ± 0.07 vs. 0.81 ± 0.07, P = 1.00; OF, 0.19 ± 0.02 vs. 0.190 ± 0.02, P = 1.00). ETM WF and disease duration can assess MPPT efficacy.

DATA CONCLUSION

Higher ETM WF demonstrates better MPPT efficacy for TAO.

EVIDENCE LEVEL

4 TECHNICAL EFFICACY: Stage 4.

Correlation between orbital immune cell subsets and clinical activity in thyroid eye disease

PURPOSE

To assess correlations between orbital immune cell subsets and the clinical activity in thyroid eye disease (TED).

METHODS

The orbital samples from 12 healthy controls and 29 TED patients (active group, n=12; inactive group, n=17) were analyzed. Total lymphocytes, CD3+T cells, CD4+T cells, CD8+ T cells, CD3+CD4+CD8+T cells (double-positive (DPT) T-cells), CD3+CD4-CD8-T cells (double negative (DNT) T-cells), B cells, natural killer (NK) cells and NKT cells were counted on flow cytometry. Correlations between the number of orbital immune cells and clinical activity score (CAS) were analyzed.

RESULTS

Age was greater in active than inactive TED patients, and in inactive TED patients than in controls (all P<0.05). TED duration was shorter in active than inactive patients (all P<0.05). FT3 and TSH levels were higher in controls than in active TED patients (P<0.05). There was no significant difference in TRAb level between active and inactive patients. There were no significant differences in smoking status, gender or FT4 level between the 3 groups (all P>0.05). The numbers of orbital total lymphocytes, CD3+ T cells, CD4+ T cells, CD8+ T cells, DNT cells, NK cells, NKT cells and CD4+/CD8+ T cells in active TED patients were significantly higher than in inactive patients and controls (all P<0.05). After adjusting for age and TED duration, the number of CD3+ T cells, CD4+ T cells, CD8+ T cells, NK cells and NKT cells were independent predictors of TED activity (P=0.03, OR=1.19; P=0.04, OR=1.69; P=0.03, OR=1.48; P=0.04, OR=2.08; P=0.03, OR=2.89, respectively).

CONCLUSIONS

Numerous immunoinflammatory cells were observed in the orbits of both active and inactive TED patients and in controls, but expression was highest in active TED patients. CD4+ T cell, CD8+ T cell, NK cell, and NKT cell counts were independent factors for the CAS in TED.

Predictive modeling of graves' orbitopathy activity based on meibomian glands analysis using in vivo confocal microscopy

OBJECTIVES

This study aims to identify indicators of disease activity in patients with graves' orbitopathy (GO) by examining the microstructural characteristics of meibomian glands (MGs) and developed a diagnostic model.

METHODS

We employed in vivo confocal microscopy (IVCM) to examine MGs in GO patients. Patients classified in the active phase were determined based on the clinical activity score (CAS). The research employed the least absolute shrinkage and selection operator (LASSO) method to select key indicators. Subsequently, a logistic regression model was constructed to predict GO disease activity.

RESULTS

A total of 45 GO patients, corresponding to 90 eyes, were included in this study. A Lasso regression algorithm was utilized to select the predictor variables. Five predictor variables were included in our diagnostic model ultimately. The area under the curve (AUC) for the training set model reached 0.959, and for the validation set was 0.969. The training set and validation set models both demonstrated high accuracy in calibration. Finally, a Nomogram chart was constructed to visualize the diagnostic model.

CONCLUSION

We constructed a diagnostic model based on microstructural indicators of MGs obtained through IVCM and offered a clinical utility for assessing GO disease activity, aiding in the diagnosis and selection of treatment strategies for GO.

Evaluation of the clinical management of Graves' Orbitopathy according to severity: a real-life Analysis

PURPOSE

Due to the clinical and prognostic implications of Graves' Orbitopathy (GO), clinical care needs to be tailored to current recommendations, but real-life information is scarce. We aim to describe GO management in a real-life setting for health care improvement.

METHODS

This is a retrospective cohort study evaluating the clinical performance of clinicians attending patients diagnosed with GO. All cases with GO from 2018 to 2021 were included in the analysis, with no exclusion criteria. We performed an evaluation of the healthcare provided to these patients, with clinical performance evaluated from diagnostic and therapeutic viewpoints. A backwards stepwise multivariate binomial logistic regression analysis was run to assess the variables associated with severity.

RESULTS

This was a cohort of 151 cases, predominantly of women in the fifth decade of life, most of whom had hyperthyroidism. There were 50 (33.1%) cases with moderate-severe GO, but none of them with sight-threatening disease. Total annualized visits were more frequent to endocrinologists than ophthalmologists, except for moderate-severe cases. Active smoking (57 cases; 37.7%), unstable hyperthyroidism (59 cases; 39.1%), and elevated maximum TSI levels (136; 90.1%) conditioned clinical care. Altogether, the performance of an imaging technique, the use of systemic corticosteroid therapy and eyelid surgery were significantly different in those with more severe GO.

CONCLUSION

Clinical care provided to patients with GO is variable and influenced by several variables. Both endocrinologists and ophthalmologists must coordinate to ensure a unified patient-tailored protocol that covers all these patients' needs.

Correlation between orbital imaging features of thyroid-associated ophthalmopathy and pupillary light reflex measurement

Purpose

This study aimed to assess the factors associated with quantitative pupillary light reflex analysis and orbital magnetic resonance imaging (MRI) indicators in thyroid-associated ophthalmopathy (TAO) patients with different TAO severities, and their diagnostic significance of dysthyroid optic neuropathy (DON).

Methods

A retrospective cross-sectional analysis was conducted on 57 patients with TAO, involving 109 orbits. Using the EUGOGO severity grading system, patients were categorized into three groups: Mild TAO (45 orbits), Moderate-to-Severe TAO (48 orbits), and DON (16 orbits). All participants underwent comprehensive ophthalmological assessments, pupillary light reflex analysis using the RAPDx device (Konan Medical), and MRI imaging (GE 3.0 Signa Creator, GE Medical Systems). MRI measurements included orbital bone wall area, extraocular muscle area, and proptosis. Differences in clinical characteristics, pupillary function indicators, and MRI-derived indicators were analyzed using Generalized Estimating Equations (GEE). Correlations and trends between Latency Onset of Constriction (LOC) and MRI indicators were assessed through Pearson multivariate analysis and linear regression models. The diagnostic value of LOC and the Volume of the Medial Orbital Wall (VMW) for diagnosing DON was further evaluated using Receiver Operating Characteristic (ROC) curve analysis.

Results

The results revealed that LOC was significantly prolonged in the DON group compared to both the Mild TAO and Moderate-to-Severe TAO groups (p < 0.05 for both). LOC demonstrated strong positive correlations with Inferior Orbital Nerve Signal Loss (IONSL) (r = 0.494, p < 0.001), Proptosis (r = 0.448, p < 0.001), and Medial Rectus Area (MRA) (r = 0.428, p < 0.001). Multivariate binary logistic regression analysis identified LOC and VMW as independent predictors of DON. A predictive model combining LOC and VMW showed excellent diagnostic performance, with an Area Under the Curve (AUC) of 0.886 (p < 0.001), sensitivity of 90.5%, and specificity of 82.4%.

Conclusion

These findings underscore the critical roles of pupillary light reflex analysis and MRI in diagnosing and evaluating TAO. The significant correlations of LOC with IONSL, Proptosis, and MRA, along with its strong predictive value alongside VMW, highlight their utility as reliable diagnostic markers for DON.

Serum levels of rapamycin predict the response of Graves' orbitopathy to sirolimus

OBJECTIVE

Compared with methylprednisolone, a greater response of Graves' orbitopathy (GO) at 24 weeks was reported in patients treated with sirolimus (rapamycin) for 12 weeks. We investigated whether serum levels of sirolimus at week-12 predict the outcome of GO at week-24.

METHODS

Retrospective investigation in 30 patients [males: 4; females: 26; age 61.3 (9.62) yr] with moderate-to-severe, active GO, treated with sirolimus (2 mg on day-one, followed by 0.5 mg QD for 12 weeks).

PRIMARY OUTCOME

serum sirolimus at week-12 in week-24 GO responders vs nonresponders, assessed by a composite evaluation.

SECONDARY OUTCOME

establishment of a cut-off value of week-12 sirolimus concentrations predictive of response to treatment.

RESULTS

At week-24, overall GO responders and nonresponders were 18 (60%) and 12 (40%), respectively. Week-12 serum sirolimus was higher in week-24 responders [4.6 (2.2) ng/mL vs 2.8 (1.6) ng/mL in nonresponders; mean difference 1.7; 95% CI from 0.1 to 3.1; P = 0.034)]. A cut-off value of week-12 serum sirolimus was established at 3.5 ng/mL; levels ≥ 3.5 ng/mL were more frequent in week-24 GO responders than in nonresponders [13/18 (72.2%) vs 3/12 (25%); OR: 7.8; 95% CI from 1.4 to 41.2; P = 0.015], with a positive predictive value of 81.2% (95% CI from 60.9 to 92.3), a sensitivity of 72.2% (95% CI from 46.5 to 90.3), and a specificity of 75% (95% CI from 42.8 to 94.5).

CONCLUSIONS

Serum levels of sirolimus at week-12 are predictive of GO response to treatment at week-24, suggesting a dose-dependent relationship with GO outcome.

Effect of intravenous methylprednisolone on serum antibody levels in thyroid eye disease

BACKGROUND/AIMS

We evaluated longitudinal autoantibody changes after intravenous methylprednisolone (IVMP), compared them with those in untreated patients and identified prognostic factors for treatment response.

METHODS

In this single-centre, retrospective, observational study, a total of 163 individuals diagnosed with moderate-to-severe thyroid eye disease were enrolled and followed for 12 months. Depending on whether IVMP was administered, we divided the patients into treatment and control groups. Based on the effect of IVMP on TSH receptor (TSH Rc) antibody level, we divided the patients into Ab declined and Ab not declined groups.We evaluated the time, group and interaction associations with the longitudinal autoantibody titres over 12 months using generalised estimating equations. Using multivariable logistic regression, we investigated the prognostic factors for a poor response to IVMP.

RESULTS

In the IVMP group, the TSH Rc antibody (Ab) titre decreased rapidly for 6 months and then decreased slowly until 12 months, becoming similar to the control group at 12 months. This suggests a difference in the decreasing pattern over time between the IVMP and control groups (group and time interaction p=0.029). Total cholesterol (OR 1.0217 (95% CI 1.0068 to 1.0370), p=0.0043) was a significant prognostic factor for the steroid response. The threshold total cholesterol value to distinguish between Ab declined and Ab not declined was 186 mg/dL.

CONCLUSION

IVMP significantly decreased the TSH Rc Ab level for the 3 months after treatment, compared with the no-treatment group, but the groups did not differ significantly after 12 months. Patients with high total cholesterol levels generally showed a poor response to IVMP.

Analysis of non-cholesterol sterols and fatty acids in patients with graves' orbitopathy: insights into lipid metabolism in relation to the clinical phenotype of disease

PURPOSE

Graves' orbitopathy (GO) is a complex inflammatory disease of the orbit. A potential link between cholesterol metabolism and the occurrence of GO is possible, but still unexplored. This study aims to investigate patients' lipid status, fatty acid content, and cholesterol homeostasis markers, all in relation to the clinical phenotype of GO.

METHODS

This cross-sectional study enrolled 89 consecutive patients with GO of varying degrees of activity and severity. Conventional lipid parameters were measured using routine biochemical methods. Concentrations of cholesterol synthesis and cholesterol absorption markers were analyzed by a GC-FID method. The percentage composition of individual fatty acids was determined by GC-FID. Total concentration of thyrotropin-receptor antibodies was measured by a binding immunoassay (Roche Diagnostics), while their stimulating activity (TSAb) was quantified using a cell-based bioassay (Quidelortho).

RESULTS

HDL-C concentration was significantly lower in patients with an active GO compared to an inactive form of GO (p = 0.032). The ApoB/ApoA1 ratio was significantly higher in a more severe GO (p = 0.029). Also, a positive correlation between LDL-C and TSAb levels (ρ = 0.255, p = 0.019) was observed. Lathosterol concentration significantly increased in more severe GO cases (p = 0.045). Moreover, the level of cholesterol synthesis-to-absorption index (CSI/CAI) positively correlated with CAS score (ρ = 0.232, p = 0.048). Palmitic acid was significantly associated with active GO (p = 0.012). The levels of desmosterol, lathosterol, CSI/CAI, and oleic acid were significantly associated with TSAb levels.

CONCLUSIONS

Alterations in patients' lipid profile and the cholesterol homeostasis were associated with a worse clinical phenotype of GO.

Treatment of Hyperthyroidism in Graves' Disease Complicated by Thyroid Eye Disease

Thyroid eye disease (TED) is the most consequential extrathyroidal manifestation or complication of Graves' disease (GD). Treatment of hyperthyroidism in GD complicated by TED is challenging. Antithyroid drugs (ATDs) and thyroidectomy do not change the natural course of TED, while radioactive iodine (RAI) is associated with a small but well-documented risk of TED de novo occurrence or its progression/worsening. In the presence of mild TED, any treatment for hyperthyroidism can be used, but should RAI treatment be selected, steroid prophylaxis (short course of low-dose prednisone) is strongly recommended if TED is of recent onset and/or risk factors for progression exist. In moderate to severe and active TED, ATDs are the preferred treatment, but thyroidectomy is a valid option. RAI ablation is generally avoided; it might be used when the clinical situation calls for it, but with extreme caution, if an aggressive treatment for TED with high-dose glucocorticoids (with or without orbital radiotherapy) is administered concomitantly. In moderate to severe and inactive TED, all 3 treatments for hyperthyroidism are acceptable, and steroid prophylaxis in RAI-treated patients should be given when risk factors for TED progression are identified. Management of sight-threatening TED represents the absolute priority, and hyperthyroidism should be controlled with ATDs until TED has been controlled. Search Strategies Current guidelines, original articles, clinical trials, systematic reviews, and meta-analyses up to June 2024 were searched using the following terms: "Graves' disease," "management of Graves' disease," "antithyroid drugs," "radioactive iodine," "thyroidectomy," "thyroid eye disease," "Graves' orbitopathy or ophthalmopathy."