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Swaify IY, Nasr HE, El Essawy RA, Elessawy KB. Periocular methotrexate versus periocular triamcinolone injections for active thyroid-associated orbitopathy: a randomized clinical trial. Jpn J Ophthalmol 2023; 67:699-710. [PMID: 37540324 DOI: 10.1007/s10384-023-01016-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 07/06/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE To assess the efficacy and safety of periocular injections of methotrexate versus triamcinolone in the management of active thyroid-associated orbitopathy. STUDY DESIGN Prospective, double-masked, randomized clinical trial. METHODS Participants with bilateral active, moderate-to-severe thyroid-associated orbitopathy were randomly assigned to receive three periocular injections of 7.5 mg methotrexate in one orbit and three periocular injections of 20 mg triamcinolone in the contralateral orbit. RESULTS Among the enrolled 25 patients, 18 patients completed the study. A statistically significant reduction of the mean clinical activity score was detected in both arms (from 5.2 ± 0.89 at baseline to 0.9 ± 1.7 at study endpoint, p-value < 0.001 in the methotrexate arm, and from 5.1 ± 0.9 at baseline to 1 ± 1.7 at study endpoint, p-value < 0.001 in the triamcinolone arm), mean proptosis also decreased in both arms (from 25.2 ± 3.4 mm at baseline to 23.8 ± 3.7 mm at study endpoint, p-value = 0.01 in the methotrexate arm, and from 24.2 ± 3.06 mm at baseline to 23.2 ± 3.3 mm at study endpoint, p-value = 0.049 in the triamcinolone arm). Lid aperture and soft tissue signs improved significantly in both arms in comparison to baseline. A statistically significant reduction in the intraocular pressure was observed in the methotrexate arm but not in the triamcinolone arm. 88.9% of patients in both arms were overall responders at 6 months. There was no significant difference in mean CAS, proptosis, lid aperture or rate of responders between the two arms at any visit. Both drugs were found to be safe with minimal local and systemic complications. CONCLUSION Periocular injections of methotrexate represent an effective and safe alternative option for the management of active, moderate-to-severe thyroid-associated orbitopathy. Although no serious complications occurred during the 6-month follow-up, the possibility of late complications such as orbital fat atrophy cannot be ruled out.
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Affiliation(s)
- Islam Y Swaify
- Ophthalmology Department, Faculty of Medicine, Cairo University, Al-Saray Street, El-Manial, Cairo, Egypt.
| | - Haytham E Nasr
- Ophthalmology Department, Faculty of Medicine, Cairo University, Al-Saray Street, El-Manial, Cairo, Egypt
| | - Rania A El Essawy
- Ophthalmology Department, Faculty of Medicine, Cairo University, Al-Saray Street, El-Manial, Cairo, Egypt
| | - Kareem B Elessawy
- Ophthalmology Department, Faculty of Medicine, Cairo University, Al-Saray Street, El-Manial, Cairo, Egypt
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Mu PW, Tang XX, Wang YN, Lin S, Wang MM, Yin QL, Shu J, Zhu BL, Li JR, Zhou L, Zeng LY, Chen YM. Comparison of two regimens for patients with thyroid-associated ophthalmopathy receiving intravenous methyl prednisolone: A single center prospective randomized trial. Exp Ther Med 2020; 20:153. [PMID: 33093891 DOI: 10.3892/etm.2020.9282] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 04/01/2020] [Indexed: 12/18/2022] Open
Abstract
Intravenous (i.v.) glucocorticoid is recommended for active moderate-to-severe thyroid-associated ophthalmopathy (TAO). However, the details of the treatment schedule are still debatable. The present prospective randomized trial was performed to compare clinical outcomes and serum cytokines between the two regimens. A cohort of 90 patients with active moderate-to-severe TAO was randomized to receive i.v. methyl prednisolone on a weekly protocol or daily scheme. The response rate was evaluated at the 12-week follow-up visit. Serum interleukin (IL)-2, IL-6 and IL-17 levels were measured in 160 patients with TAO, 60 patients with isolated Graves' disease (GD) and 60 normal control (NC) at baseline, as well as patients with active moderate-to-severe TAO at the 12th week after treatment. The daily scheme had a higher response rate than the weekly protocol without a significant difference (77.8 vs. 63.6%, P>0.05). No major adverse events were recorded under either regimen. Overall, minor events were more common on the daily scheme (11.36 vs. 4.35%, P<0.05)than on the weekly protocol, whereas the deterioration of eye symptoms (two patients) was only reported on the weekly protocol. At baseline, the IL-17 level in the TAO group was higher than that in the isolated GD and NC groups (P<0.05). In addition, the IL-17 level in the active TAO group was higher than that in the inactive TAO group (P<0.05). Furthermore, the IL-17 level had significantly decreased under the two regimens at the 12-week visit (P<0.05). In conclusion, for patients with active moderate-to-severe TAO, daily i.v. glucocorticoid therapy has a relative higher response rate than the weekly protocol with a few more minor adverse events. These two regimens have their own merits with regard to adverse effects. IL-17 has the potential to be a biomarker for evaluating TAO activity and treatment effects.
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Affiliation(s)
- Pan-Wei Mu
- Department of Endocrinology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Xi-Xiang Tang
- Advanced Medical Center, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Yi-Na Wang
- Advanced Medical Center, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Shuo Lin
- Department of Endocrinology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Man-Man Wang
- Department of Endocrinology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Qiong-Li Yin
- Advanced Medical Center, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Jiong Shu
- Department of Endocrinology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Bi-Lian Zhu
- Advanced Medical Center, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Jing-Ren Li
- Department of Endocrinology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Li Zhou
- Department of Endocrinology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Long-Yi Zeng
- Department of Endocrinology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Yan-Ming Chen
- Department of Endocrinology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, P.R. China
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Abstract
Sudden deterioration of visual functions warrants comprehensive ophthalmic examination with evaluation for systemic association. Cerebral venous thrombosis (CVT) is an uncommon disorder that can present with neurological deficits. We report a young female patient aged 28 years who presented with severe headache and sudden diminution of vision and was subsequently diagnosed with hyperthyroidism and CVT. Management of CVT and hyperthyroidism hastened full recovery of visual functions.
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Douglas RS, Tsirbas A, Gordon M, Lee D, Khadavi N, Garneau HC, Goldberg RA, Cahill K, Dolman PJ, Elner V, Feldon S, Lucarelli M, Uddin J, Kazim M, Smith TJ, Khanna D. Development of criteria for evaluating clinical response in thyroid eye disease using a modified Delphi technique. ACTA ACUST UNITED AC 2009; 127:1155-60. [PMID: 19752424 DOI: 10.1001/archophthalmol.2009.232] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To identify components of a provisional clinical response index for thyroid eye disease using a modified Delphi technique. METHODS The International Thyroid Eye Disease Society conducted a structured, 3-round Delphi exercise establishing consensus for a core set of measures for clinical trials in thyroid eye disease. The steering committee discussed the results in a face-to-face meeting (nominal group technique) and evaluated each criterion with respect to its feasibility, reliability, redundancy, and validity. Redundant measures were consolidated or excluded. RESULTS Criteria were parsed into 11 domains for the Delphi surveys. Eighty-four respondents participated in the Delphi 1 survey, providing 220 unique items. Ninety-two members (100% of the respondents from Delphi 1 plus 8 new participants) responded in Delphi 2 and rated the same 220 items. Sixty-four members (76% of participants) rated 153 criteria in Delphi 3 (67 criteria were excluded because of redundancy). Criteria with a mean greater than 6 (1 = least appropriate to 9 = most appropriate) were further evaluated by the nominal group technique and provisional core measures were chosen. CONCLUSIONS Using a Delphi exercise, we developed provisional core measures for assessing disease activity and severity in clinical trials of therapies for thyroid eye disease. These measures will be iteratively refined for use in multicenter clinical trials.
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Affiliation(s)
- Raymond S Douglas
- Department of Ophthalmology, Jules Stein Eye Institute and David Geffen School of Medicine at University of California, Los Angeles, CA 90095, USA
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Abstract
Introduction Thyroid eye disease (TED), also known as Graves opthalmopathy is the most common orbital disease and affects 25–50% of patients with Graves' disease (Kuryan et al 2008). Most patients are only mildly affected, suffering ocular irritation with redness and watering, ‘staring eyes' due to retraction of the eyelids, exophthalmos (protrusion of the eyeballs) and periorbital swelling (Figure 1). A minority of patients (around 28%) will develop ocular motility problems, leading to diplopia (double vision), exposure/damage to the cornea and optic neuropathy (Kumar & Clarke 2002, Forbes & Jackson 2003, Meyer 2006).
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Affiliation(s)
- Neil C Modi
- Torbay Hospital, Lawes Bridge, Torquay TQ2 7AA.
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Hornez N, Morell-Dubois S, Woillez JP, Queyrel V, Charlanne H, Launay D, Lambert M, Hachulla E, Wemeau JL, Hatron PY. [Euthyroid Graves' disease: a case report]. Rev Med Interne 2009; 30:988-90. [PMID: 19299047 DOI: 10.1016/j.revmed.2009.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2008] [Revised: 01/24/2009] [Accepted: 02/07/2009] [Indexed: 11/18/2022]
Abstract
Euthyroid Graves' disease is defined as an ophtalmopathy without any clinical or biological signs of thyroid dysfunction. It highlights the apparent dissociation between orbitopathy and thyroid disease. Diagnosis is often too late while early treatment could really improve functional prognosis. We report a 57-year-old woman who presented with this entity and that illustrates both the diagnostic difficulty and disease course after intravenous corticosteroid therapy.
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Affiliation(s)
- N Hornez
- Service de médecine interne, hôpital Huriez, CHRU de Lille, rue Michel-Polonovski, Lille cedex, France.
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Rees Smith B, Sanders J, Furmaniak J. Implications of new monoclonal antibodies and the crystal structure of the TSH receptor for the treatment and management of thyroid diseases. Biomark Med 2008; 2:567-76. [DOI: 10.2217/17520363.2.6.567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Autoantibodies to the thyroid-stimulating hormone receptor (TSHR) cause the hyperthyroidism of Graves’ disease and contribute to Graves’ eye signs. Human monoclonal TSHR autoantibodies prepared from patients’ lymphocytes have important clinical applications in terms of their ability to stimulate TSHR-containing tissues. Also, TSHR monoclonal antibodies that act as antagonists may well be useful in treating Graves’ eye disease. Recently, the high-resolution (2.55 Å) crystal structure of the TSHR in complex with a monoclonal thyroid-stimulating autoantibody has been determined, and this provides key insights into how the autoantibodies interact with the receptor. Furthermore, the structure can be used in the rational design of small molecules that will disrupt receptor binding by thyroid-stimulating autoantibodies, thus providing new strategies to control TSHR activation in addition to monoclonal antibodies.
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Affiliation(s)
- Bernard Rees Smith
- FIRS Laboratories, RSR Ltd, Parc Ty Glas, Llanishen, Cardiff, CF14 5DU, UK
| | - Jane Sanders
- FIRS Laboratories, RSR Ltd, Parc Ty Glas, Llanishen, Cardiff, CF14 5DU, UK
| | - Jadwiga Furmaniak
- FIRS Laboratories, RSR Ltd, Parc Ty Glas, Llanishen, Cardiff, CF14 5DU, UK
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&NA;. In addition to antithyroid therapy, some patients with Graves?? hyperthyroidism may require treatment for psychiatric and ocular symptoms. DRUGS & THERAPY PERSPECTIVES 2007. [DOI: 10.2165/00042310-200723090-00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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