Pediatric thyroid eye disease--the Singapore experience

A Review of Pediatric Ophthalmic Tumors

Tumors of the eye, orbit, and ocular adnexa can arise in the pediatric population. These entities can be both vision- and life-threatening and may be associated with systemic disease. Given their relative rarity, pediatricians must be aware of these conditions and understand what findings warrant immediate referral to an ophthalmologist for initiation of further testing. We aimed to review these conditions and highlight clinical features to promote awareness and expedite diagnosis. Tumors are subdivided into the following categories for review: anterior tumors of the eyelid and ocular surface, orbital tumors, and intraocular tumors.

Longitudinal follow-up of pediatric Graves' disease in preschool children: Clinical characteristics and a case report

RATIONALE

Pediatric Graves' disease at preschool age is a rare condition. Previous reports have indicated that adolescents with this disease are girls. Pediatric Graves' ophthalmopathy in young children is rare, and long-term follow-up reports are lacking.

PATIENT CONCERNS

The patient had hyperthyroidism and bilateral proptosis for 2 years, but she was only 4 years old.

DIAGNOSES

The blood test revealed hyperthyroidism and the ophthalmic examination revealed proptosis. The patient had Graves' disease and Graves' ophthalmopathy.

INTERVENTIONS

Initially, she was followed up in the pediatric department. Bilateral proptosis developed, and she was brought to the ophthalmology department for assistance. Orbital computed tomography revealed borderline enlargement of the extraocular muscles bilaterally. Other initial clinical findings included bilateral upper and lower eyelid trichiasis and mild punctate epithelial erosions of the cornea. She received conservative medical treatment in the ophthalmology department.

OUTCOMES

Remission of hyperthyroidism was achieved 2 years after medical control. No elevated intraocular pressure, strabismus, or optic neuropathy developed during follow-up. Significant cosmetic improvement and gradual resolution of punctate epithelial erosions were found over 10 years. Finally, the patient had only mild bilateral lower trichiasis.

LESSONS

Longitudinal follow-up revealed that the ocular manifestations of proptosis and eyelid trichiasis may have good outcomes. Proptosis gradually improved as the patient grew up.

Pediatric Graves' orbitopathy: a multicentre study

PURPOSE

Graves' orbitopathy (GO) is a rare condition in children often considered to be a less severe condition than at an older age. The aim of our study was to analyse if there are any factors that distinguish paediatric from adult GO in order to provide guidelines for assessing and managing paediatric GO.

METHODS

Study design is a multicentre retrospective observational case series; 115 paediatric patients diagnosed with GO who visited our university medical centres in the Netherlands and Iran between 2003 and 2019 were submitted for complete ophthalmological examinations, serological testing and/or orbital imaging. Main outcome measures focussed on the natural course and clinical picture as well as medical and surgical treatment in paediatric GO.

RESULTS

Clinical findings included proptosis (n = 97; 84.3%), eyelid retraction (n = 77; 67%) and diplopia (n = 13; 11.3%). Ninety-two patients (80%) presented with mild disease, 21 (18.3%) with moderate-severe disease and two (1.7%) with severe GO. Five patients (4.3%) underwent intravenous glucocorticoids and 25 patients underwent orbital decompression surgery. Strabismus surgery due to primary involvement of extraocular muscles was performed in two patients (1.7%). Overall, rehabilitative surgical treatment was planned in 31 patients (26.9%) with inactive disease. Two patients experienced reactivation of the disease.

CONCLUSION

Despite the fact that paediatric and adult GO are considered two separate entities, they might be the same disease with two different clinical phenotypes. Paediatric GO population presents with a comparable clinical picture regarding both soft tissue involvement and proptosis, which may require surgical intervention. Proptosis was present in the majority of paediatric GO patients. Orbital decompression was performed in 21.7% of patients.

A retrospective study of pediatric thyroid eye disease: the Asian experience

AIM

To study the clinical presentation, disease characteristics, and management approach for children with thyroid eye disease (TED) over a 10 year period in a multidisciplinary Paediatric Thyroid Eye Disease Clinic at a tertiary care referral center.

METHODS

Retrospective case series of patients with TED at Kandang Kerbau Women's and Children's Hospital (KKWCH) Singapore between August 2006 to June 2015. The diagnosis of TED was clinical based on the Bartley criteria. Ophthalmic examination findings, systemic thyroid function and ophthalmological intervention were recorded.

RESULTS

Nineteen subjects with pediatric TED were studied. The median age at diagnosis was 12.5 years (range 6-17). The onset of TED was at the same time as their thyroid disease in half of these patients (52.6%) of which all were hyperthyroid except one. The most common signs at TED diagnosis were proptosis (84.2%), lid retraction (63.2%), acquired epiblepharon (63.2%). All patients were inactive and none had evidence of compressive optic neuropathy. TED remained stable in all patients except for one who developed worsening proptosis with exposure keratopathy. No patients were prescribed steroids (oral or intravenous) or had orbital decompression surgery. The most debilitating morbidity was acquired epiblepharon of which out of 12 patients, one had everting sutures and three were offered surgical correction.

CONCLUSIONS

Paediatric TED subjects exhibit milder clinical manifestations compared to adults. Acquired epiblepharon causes most significant visual morbidity by compromising the corneal surface. Being cognizant of the subtleties of pediatric TED will permit the discerning clinician to effectively manage such cases accordingly.

Severe pediatric Graves orbitopathy in adolescents of African origin

This article reports on two cases of severe pediatric Graves orbitopathy (GO) in two adolescents of African origin. Two black male adolescents presented with highly active GO and signs of beginning compressive optic neuropathy. Neither of them were smokers nor had a family history of GO. Besides urgent referral to pediatric endocrinologists, intravenous methylprednisolon pulse therapy was initiated. In spite of the fluctuating thyroid hormone levels in the initial phase of antithyroid therapy, intravenous steroid administration stopped the progression of malignant GO rapidly in both of our patients without any considerable side effects. Although the course of GO during childhood is considered to be mild, severe, sight threatening GO-requiring immunosuppression-may occur at young age, as in the reported adolescent patients of African descent.

Severe Pediatric Thyroid Eye Disease: Surgical Case Series

Thyroid eye disease (TED) usually has mild manifestations in pediatric patients, and orbital decompression is rarely necessarily. The authors present the clinical course of 3 pediatric patients age 16 or younger at the time of decompression surgery with severe orbitopathy. Case 1 is a 9-year-old prepubertal Asian-American female with Graves' disease and TED who underwent balanced decompression for compressive optic neuropathy. Case 2 is a 14-year-old white female with Graves' disease and TED who underwent balanced decompression for compressive optic neuropathy, stretch optic neuropathy, and globe subluxation. Case 3 is a 14-year-old African-American male with unilateral euthyroid TED who underwent staged right-sided lateral, medial, and floor decompressions for asymmetric proptosis. All cases also had disfiguring proptosis and exposure keratopathy, and in all cases, surgery successfully ameliorated the indications. Children, both pre- and post-pubertal, can rarely manifest visually threatening severe orbitopathy due to TED. This represents the first reports of thyroid-related optic neuropathy and globe subluxation in pediatric patients. Further studies examining the mechanism responsible for the disparities in pediatric and adult TED are warranted.

Thyroid eye disease: a Southeast Asian experience

AIM

To study the demographics, comorbidities, clinical manifestations and treatment methods of thyroid eye disease (TED) in Singapore.

METHODS

In this retrospective case series, we analysed the case records of all patients with TED who presented at our multidisciplinary Thyroid Eye Clinic from November 2002 to October 2012.

RESULTS

There were a total of 174 patients-111 female patients (63.8%) and 63 male patients (36.2%). The majority of the patients were ethnically Chinese (80.5%), followed by Malay (10.3%) and Indian (6.3%). The mean age was 40.2 years (SD±15.5, range 0.3-87.0). The commonest sign on ophthalmic examination was eyelid retraction (62.1%), followed by proptosis (61.0%) and lid lag (57.5). Acquired epiblepharon and corneal erosions were noted in 11.5% and 29.3% respectively. Eight patients (4.6%) had dysthyroid optic neuropathy. The mean exophthalmometry reading was 18.8 mm (SD±3.32, range 10.0-28.0). Mild, moderate and severe disease was noted in 71.3%, 20.7% and 8.0% respectively. Thyroid dysfunction was managed with anti-thyroid medication only (40.2%), β blockers (19.5%), thyroxine replacement (14.4%), radioactive iodine (14.4%) and block-replace regime (9.8%). Clinically significant active orbitopathy was managed with intravenous corticosteroids (12.1%). Surgical procedures consisted of thyroidectomy (10.3%), eyelid surgery (8.6%), orbital decompression (7.5%), epiblepharon correction (2.3%) and strabismus surgery (0.6%).

CONCLUSIONS

Corneal erosion secondary to acquired epiblepharon is a common sign in East Asian patients with TED, thus increased awareness among physicians should be encouraged. Mean exophthalmometry values and frequencies of upper eyelid retraction and oedema are lower in East Asian patients compared with Caucasian patients. Among Singapore's multi-ethnic population, Malay patients with TED had the highest exophthalmometry reading.