Assessment of quality of life and depression in Korean patients with Graves' ophthalmopathy

The role of lateral rectus muscle resection for severe esotropia after medial rectus muscle myectomy in Graves' ophthalmopathy

PURPOSE

Persistent diplopia after rectus muscle myectomy is not uncommon but challenging in patients with Graves' ophthalmopathy. We investigated the role of lateral rectus muscle resection for patients after medial rectus muscle myectomy in Graves' ophthalmopathy.

METHODS

We retrospectively reviewed and collected data from patients with persistent diplopia after medial rectus muscle myectomy for Graves' ophthalmopathy who underwent unilateral or bilateral lateral rectus muscle resection. The eyeball deviations in the primary and reading positions before and after the operation were measured. A successful surgical outcome was defined as having less than five prism diopters (PD) in the primary gaze and functional binocular vision in the central 30° field postoperatively.

RESULTS

A total of fifteen patients were included (mean post-myectomy deviation: 35.9 PD, range: 14 to -75 PD). The lateral rectus muscle resection after medial rectus muscle myectomy achieved an 80.0% success rate, with one patient over-corrected and two patients under-corrected.

CONCLUSIONS

The lateral rectus muscle resection is an effective and predictable procedure for managing residual esotropia in Graves' ophthalmopathy patients who have previously undergone medial rectus muscle myectomy.

Use of extreme gradient boosting, light gradient boosting machine, and deep neural networks to evaluate the activity stage of extraocular muscles in thyroid-associated ophthalmopathy

PURPOSE

To develop a machine learning model to evaluate the activity stage of extraocular muscles in thyroid-associated ophthalmopathy (TAO).

METHODS

This study retrospectively analysed data from patients with TAO who underwent contrast-enhanced magnetic resonance imaging (MRI) from 2015 to 2022. Three independent machine learning models, namely, extreme gradient boosting (XGBoost), light gradient boosting machine (LightGBM), and deep neural networks (DNNs), were constructed using common clinical features. The performance of these models was compared using evaluation metrics such as the area under the receiver operating curve (AUC), accuracy, precision, recall, and F1 score. The importance of features was explained using Shapley additive explanations (SHAP).

RESULTS

A total of 2561 eyes of 1479 TAO patients were included in this study. The original dataset was randomly divided into a training set (80%, n = 2048) and a test set (20%, n = 513). In the performance evaluation of the test set, the LightGBM model had the best diagnostic performance (AUC 0.9260). According to the SHAP results, features such as conjunctival congestion, swollen caruncles, oedema of the upper eyelid, course of TAO, and intraocular pressure had the most significant impact on the LightGBM model.

CONCLUSION

This study used contrast-enhanced MRI as an objective evaluation criterion and constructed a LightGBM model based on readily accessible clinical data. The model had good classification performance, making it a promising artificial intelligence (AI)-assisted tool to help community hospitals evaluate the inflammatory activity of extraocular muscles in TAO patients in a timely manner.

Altered dynamic brain activity and functional connectivity in thyroid-associated ophthalmopathy

Although previous neuroimaging evidence has confirmed the brain functional disturbances in thyroid-associated ophthalmopathy (TAO), the dynamic characteristics of brain activity and functional connectivity (FC) in TAO were rarely concerned. The present study aims to investigate the alterations of temporal variability of brain activity and FC in TAO using resting-state functional magnetic resonance imaging (rs-fMRI). Forty-seven TAO patients and 30 age-, gender-, education-, and handedness-matched healthy controls (HCs) were enrolled and underwent rs-fMRI scanning. The dynamic amplitude of low-frequency fluctuation (dALFF) was first calculated using a sliding window approach to characterize the temporal variability of brain activity. Based on the dALFF results, seed-based dynamic functional connectivity (dFC) analysis was performed to identify the temporal variability of efficient communication between brain regions in TAO. Additionally, correlations between dALFF and dFC and the clinical indicators were analyzed. Compared with HCs, TAO patients displayed decreased dALFF in the left superior occipital gyrus (SOG) and cuneus (CUN), while showing increased dALFF in the left triangular part of inferior frontal gyrus (IFGtriang), insula (INS), orbital part of inferior frontal gyrus (ORBinf), superior temporal gyrus (STG) and temporal pole of superior temporal gyrus (TPOsup). Furthermore, TAO patients exhibited decreased dFC between the left STG and the right middle occipital gyrus (MOG), as well as decreased dFC between the left TPOsup and the right calcarine fissure and surrounding cortex (CAL) and MOG. Correlation analyses showed that the altered dALFF in the left SOG/CUN was positively related to visual acuity (r = .409, p = .004), as well as the score of QoL for visual functioning (r = .375, p = .009). TAO patients developed abnormal temporal variability of brain activity in areas related to vision, emotion, and cognition, as well as reduced temporal variability of FC associated with vision deficits. These findings provided additional insights into the neurobiological mechanisms of TAO.

Increasing the Repertoire for Depression Care: Methods and Challenges of a Randomized Controlled Trial of Peer Support for Vulnerable Older Adults

OBJECTIVE

Low-income White and older adults of color face barriers to depression care. Our purpose is to describe the methods and challenges encountered during the implementation of a randomized controlled trial to test the effectiveness of a peer support depression care intervention for low-income White and older adults of color during the COVID-19 pandemic.

METHODS

Peer Enhanced Depression Care (Peers) is an 8-week community-based intervention that uses peer mentors who are trained and supervised to provide social support and self-care skills to depressed older adults. The effectiveness of the intervention in reducing depression will be evaluated by following a sample of older adults recruited in the community over a 12-month period. Target enrollment is 160 older adults. We hypothesize that participants randomized to the Peer Enhanced Depression Care intervention will experience greater decrease in depressive symptoms compared to participants randomized to the social interaction control. We provide lessons learned regarding the recruitment of BIPOC and White low-income older adults and peer mentors during the COVID-19 pandemic.

RESULTS

Recruitment challenges occurred in primary care clinics that were unable to accommodate recruitment efforts during the pandemic. This led to focused outreach to community-based organizations serving older adults. Challenges to participant recruitment have included barriers related to stigma, distrust, as well as unfamiliarity with research. Peer mentor recruitment was facilitated by existing government-supported resources.

CONCLUSIONS

This study will provide knowledge regarding the effectiveness, mechanism, and processes of delivering an informal psychosocial intervention such as peer support to a vulnerable older adult population.

Measuring Health-Related Quality of Life in Thyroid Eye Disease

Health-related quality of life (HQOL) is a concept that aims to understand the totality of an individual's experience of their disease state. This can include the physical, psychosocial, emotional, and psychological effects of a disease state. A complex and multifactorial concept, HQOL can be challenging to measure accurately and reliably. Thyroid eye disease (TED), as a multifaceted physically debilitating and facial disfiguring disorder, presents unique challenges and opportunities in the measurement of HQOL. Multiple distinct tools have been developed for this purpose, each has been constructed, assessed, and utilized. This discussion surveys the landscape of TED-related QOL measurement and presents challenges for the future. Clinicians and clinical researchers should implement TED-related QOL measurement as part of routine TED care and as a primary outcome in TED clinical trials. We recommend utilizing the Graves' ophthalmopathy (GO)-QOL routinely in clinical practice and as a primary outcome in TED clinical trials. If the GO-QOL is too time-consuming or in mild TED, a faster alternative is the TED-QOL.

An Intelligent Diagnostic System for Thyroid-Associated Ophthalmopathy Based on Facial Images

Background

Thyroid-associated ophthalmopathy (TAO) is one of the most common orbital diseases that seriously threatens visual function and significantly affects patients’ appearances, rendering them unable to work. This study established an intelligent diagnostic system for TAO based on facial images.

Methods

Patient images and data were obtained from medical records of patients with TAO who visited Shanghai Changzheng Hospital from 2013 to 2018. Eyelid retraction, ocular dyskinesia, conjunctival congestion, and other signs were noted on the images. Patients were classified according to the types, stages, and grades of TAO based on the diagnostic criteria. The diagnostic system consisted of multiple task-specific models.

Results

The intelligent diagnostic system accurately diagnosed TAO in three stages. The built-in models pre-processed the facial images and diagnosed multiple TAO signs, with average areas under the receiver operating characteristic curves exceeding 0.85 (F1 score >0.80).

Conclusion

The intelligent diagnostic system introduced in this study accurately identified several common signs of TAO.

Altered Long- and Short-Range Functional Connectivity Density in Patients With Thyroid-Associated Ophthalmopathy: A Resting-State fMRI Study

Background and Purpose

Although previous neuroimaging studies have demonstrated emotion- and psychology-associated brain abnormalities in patients with thyroid-associated ophthalmopathy (TAO), the changes of brain functional connectivity in TAO were seldom focused. We aimed to investigate interregional and intraregional functional interactions in patients with TAO by using resting-state functional MRI (rs-fMRI) with long- and short-range functional connectivity density (FCD) analysis.

Methods

Thirty patients with TAO and 30 well-matched healthy controls (HCs) were recruited in our study. Long- and short-range FCD values were calculated and compared between the two groups. Correlations between long- and short-range FCD values and clinical indicators were analyzed.

Results

Compared with HCs, patients with showed both increased long- and short-range FCDs in the left middle frontal gyrus (MFG), orbital part of superior frontal gyrus (ORBsup), and dorsolateral part of superior frontal gyrus (SFGdor); meanwhile, both decreased long- and short-range FCDs in bilateral postcentral gyrus (PoCG), left superior parietal gyrus (SPG), and inferior parietal (IPL). In addition, patients with TAO showed increased short-range FCD in the right SFGdor, bilateral medial part of superior frontal gyrus (SFGmed), left orbital part of middle frontal gyrus (ORBmid), and orbital part of inferior frontal gyrus (ORBinf), as well as decreased short-range FCD in the right supplementary motor area (SMA) and the left paracentral lobule (PCL) than HCs. Moreover, the short-range value in the left SFGdor showed a negative correlation with Montreal Cognitive Assessment (MoCA) score (r = −0.501, p = 0.005).

Conclusion

Our findings complemented the functional neural mechanism of TAO, and provided potential neuroimaging markers for assessing the psychiatric, visual, and emotional disturbances in patients with TAO.

Ocular surface disease in thyroid eye disease: A narrative review

Ocular surface disease (OSD) in the setting of thyroid eye disease (TED) is traditionally thought of as a natural consequence of anatomical changes such as proptosis and corneal exposure. However, a growing body of research suggests that ocular surface inflammation and multi-factorial changes to the homeostasis of the ocular surface contribute substantially to the OSD seen in TED patients. In this paper we review the existing literature which highlights the work and existing theories underlying this new paradigm shift.

Quality of Life in Patients with Chronic Thyroid Eye Disease in the United States

INTRODUCTION

Thyroid eye disease (TED) is an autoimmune condition producing ocular pain, dysmotility, and ocular structure and function changes. As disease activity changes, redness, swelling, and pain can improve, but eye comfort, appearance, and motility alterations often persist. There are limited data on chronic TED patient-reported outcomes. This study examined chronic US TED patient-reported symptoms and quality of life (QOL).

METHODS

Existing data from an online survey regarding chronic TED signs/symptoms and patient QOL were retrospectively examined. The Graves' Ophthalmopathy QOL instrument (GO-QOL; 0-100, 100 = highest QOL) evaluated overall, appearance, and vision-related QOL. Influencing factors were examined by stratifying patients into low (overall QOL ≤ 50), moderate (> 50 and < 75), and high (≥ 75) QOL categories.

RESULTS

One hundred patients (47 women, 81 Caucasian, 45.2 ± 7.6 years) were included. The duration of inactive TED was 3.0 ± 4.6 years and total duration of TED was 5.8 ± 5.9 years. Patients reported an average of 20 doctor visits/year and high prevalence of anxiety (34%) and depression (28%). Prior TED treatments for the polled population included systemic corticosteroids during active TED (25%), orbital radiation (5%), and surgery (25%). The overall GO-QOL score was 60.5 ± 21.8 (vision-related: 58.6 ± 24.0, appearance-related: 62.3 ± 25.1). Patients with low QOL more frequently reported hypothyroidism, anxiety, and a larger number of chronic TED signs/symptoms (average: 4.2). Compared to high QOL patients, low QOL patients had more pain (39% vs. 13%), blurry vision (30% vs. 17%), and diplopia (27% vs. 3%, all p ≤ 0.025). Additionally, the low QOL group more often had TED-specific surgical history (45% vs. 10%, p = 0.002), more often reported disability/unemployment (21% vs. 3%, p = 0.055), and had a higher number of doctor visits (40 vs. 5 visits/person/year, p < 0.001).

CONCLUSION

TED severely impacts patient QOL, despite becoming stable and chronic. Patients reported vision and appearance impairment and psychosocial impact long after acute TED had subsided.

Quality of Life in Thyroid Eye Disease: A Systematic Review

PURPOSE

The aim of this systematic review is to provide 1) an understanding of the components of quality of life (QOL) questionnaires and 2) an up-to-date insight of the types of QOL questionnaires available, strengths and limitations based on current literature.

METHODS

A literature search was conducted from 18 to 21 of February 2019 using 6 major databases: Cochrane Library, Ovid Medline, PubMed, Scopus, Taylor and Francis, and Web of Science. All papers were skimmed by title and abstract to determine whether the paper fulfilled the screening criteria. In cases of uncertainty, the paper was read in totality to justify its inclusion. After that, duplicates were eliminated and the remainder was subjected to a second set of inclusion and exclusion criteria before finalizing the list of included studies.

RESULTS

An initial search returned with 402 studies, which were subsequently filtered using prespecified criteria to 27 studies to collate information regarding questionnaires assessing QOL of thyroid eye disease patients.

CONCLUSIONS

The QOL of thyroid eye disease patients is best assessed using disease-specific questionnaires. Among the different types of questionnaires, the Graves Ophthalmopathy Quality of Life (GO-QOL) questionnaire is preferred due to its' ability to explore QOL in-depth and proven efficacy in many countries after cultural adaptation at the expense of time. Single-item questionnaires like the Thyroid Eye Disease Quality of Life (TED-QOL) are more suitable as screening tools in busy metropolitan settings while semi-structured interviews are important in developing new ways of assessing the QOL of thyroid eye disease patients.

Clinical and Radiological Findings in Patients with Newly Diagnosed Graves' Ophthalmopathy

BACKGROUND

Graves' ophthalmopathy is the most common extrathyroidal manifestation of Graves' disease. The objective of this study was to investigate the clinical ophthalmological and MRI findings in newly diagnosed Graves' ophthalmopathy.

METHODS

This study included 36 newly diagnosed Graves' disease patients and 23 control participants. Patients and control participants underwent detailed ophthalmologic examination. In addition, all subjects underwent orbital MRI examination; and sizes, cross-sectional areas, and signal intensities of extraocular muscles were also measured.

RESULTS

Based on MRI measurements, the mean exophthalmos in the left eye was significantly higher in the patient group when compared to those of controls (2.04 ± 0.29 vs. 1.85 ± 0.15 cm, p = 0.003). The mean long diameter of inferior oblique muscle in both the right and left eyes were significantly shorter in patients when compared to those of controls (p = 0.001, p = 0.002, resp.); however, the mean long diameter of superior oblique in the left eye was longer in patients than those of controls (p = 0.001). Patients had significantly higher superior oblique muscle signal intensity than those of controls in the right eye (p = 0.01). There was no significant difference for the other parameters between the patient and control groups.

CONCLUSION

Our findings suggest that there is no obvious change in MRI examination despite clinical ophthalmological findings in patients with newly diagnosed Graves' ophthalmopathy. Unnecessary MRI examination should be avoided in this patient group due to unsatisfactory cost-effectiveness.

Initial Postoperative Alignment in Strabismus Related to Thyroid Eye Disease

PURPOSE

To investigate the surgical outcome according to the initial postoperative angle of deviation in patients with thyroid eye disease.

METHODS

The medical records of patients who underwent strabismus surgery were retrospectively reviewed. The patients were divided into overcorrection (> 5 prism diopters [PD]), full correction, or undercorrection (> 5 PD) groups, according to the angle of deviation on postoperative day 1. The surgical outcome was considered successful when there was no diplopia vertically (< 5 PD) and horizontally (< 10 PD) at primary gaze. Surgical success rates were evaluated according to the initial postoperative angle of deviation at the final visit.

RESULTS

Seventy-eight patients were enrolled in this study. The mean age of the patients was 53.4 ± 9.5 years, and the mean follow-up duration was 17.4 ± 8.7 months. There were 51 patients with hypotropia and 27 patients with esotropia. Success rates for hypotropia were higher in the undercorrection (80.0%) and full correction (66.7%) groups than in the overcorrection (35.7%) group on postoperative day 1 (P = .02). Regarding esotropia, the success rates were higher in the undercorrection (84.6%) and full correction (83.3%) groups than in the overcorrection (37.5%) group on postoperative day 1 (P = .02). Reoperation for residual or overcorrected strabismus was performed in 15 patients (29.4%) with hypotropia and 7 patients (25.9%) with esotropia.

CONCLUSIONS

Intended minimal undercorrection or full correction after hypotropia and esotropia surgery during early postoperative periods could improve surgical success rates in patients with thyroid eye disease. [J Pediatr Ophthalmol Strabismus. 2021;58(1):23-27.].

Assessing the quality of life in Indian Graves' orbitopathy patients and validation of Hindi version of GO-QOL questionnaire

Purpose:

To validate the GO-specific quality of life (QOL) questionnaire in Hindi language and to determine the correlation of scores (visual functioning and appearance) with disease severity and activity.

Methods:

We recruited 114 consecutive patients with GO attending Endocrinology Clinic at tertiary care center. Eye examination was performed, and QOL was assessed by questionnaire.

Results:

The questionnaire was validated by 50 GO patients and test-retest reliability was performed in 15 patients. Hindi version GO-QOL was administered in 49 GO patients. GO was mild in 51.0% and sight-threatening in only 2.0% of cases. Orbitopathy was clinically active in only 10 (20.4%) cases. The GO-QOL scores (median) for visual function and appearance were 81.3 and 62.5, respectively. Patients with moderate-to-severe and sight-threatening GO had significantly lower median appearance scores (56.3 vs. 68.5, P = 0.01) compared to mild disease but no difference in visual scores. Patients with active disease had significant lower median visual function (53.1 vs. 85.7, P = 0.009) and psychosocial (appearance) scores (40.6 vs. 68.8, P = 0.03) compared to inactive disease. On multivariate regression analysis of GO-QOL scores, extraocular eye movement involvement (EOM), proptosis, and severity of eye disease were significantly associated with visual functioning while appearance was significantly associated only with the severity of eye disease.

Conclusion:

GO-QOL scores were significantly reduced in patients with GO.

Sports participation and quality of life in individuals with visual impairment

BACKGROUND

The positive effects of sports participation on health can be an important issue for rehabilitation of visually impaired individuals.

AIMS

Our aim was to determine the relationship between sports participation and quality of life in individuals with visual impairment.

METHODS

The study included 100 athletes who participated in national games for people with visual impairment and 100 subjects who did not participate in sports as the control group. The two groups were matched according to age, gender, visual acuity and visual field. The Short-Form Health Survey (SF-36) was applied for assessment of quality of life.

RESULTS

All subjects had best corrected visual acuity less than 6/60 and/or visual field less than central 10 degrees in radius in the better eye. The sociodemographic characteristics of the study and control groups were similar except the level of education being higher in the athlete group and level of income higher in the control group. All of the SF-36 scores were higher among athletes compared to controls. Duration of sports activities (years) was positively correlated with Physical Functioning score. There were no significant relations between SF-36 scores and weekly sports participation time (hours). Athletes who had visual loss at an earlier age had better scores in Physical Functioning and Role Limitations due to Physical Problems.

CONCLUSIONS

Sports activities had positive relationships with all domains of the quality of life in individuals with visual impairment. Thus, appropriate sports activities would increase the success of rehabilitation programs and their quality of life.

Surgical Outcomes of Endoscopic Medial Orbital Wall Decompression

STUDY DESIGN

Retrospective chart review.

PURPOSE

The aim of this study was to evaluate the surgical outcomes and complications after endoscopic medial orbital wall decompression.

METHOD

From November 2016 to July 2017, we retrospectively reviewed 40 eyes of 20 patients who had undergone orbital decompression because of thyroid ophthalmopathy and other causes of proptosis.The eyes were classified into 2 groups: orbits which received only endoscopic medial wall decompression, and orbits which received both endoscopic medial wall decompression and transconjunctival inferior wall decompression. Statistical analysis was performed for all data generated. The preoperative and 3-month postoperative follow-up examinations for all patients were assessed by Hertel ophthalmometry, interpalpebral fissure, marginal reflex distance 1, Goldmann applanation tonometry, diplopia test, and Grave ophthalmopathy specific quality of life survey.

RESULTS

Endoscopic medial wall decompression was performed in 17 of the total 40 eyes, and endoscopic medial wall decompression and transconjunctival inferior wall decompression was performed in the remaining 23 eyes. Proptosis improved from 20.4 ± 1.16 mm preoperatively to 16.8 ± 1.02 mm postoperatively in the endoscopic medial wall approach group, and from 20.8 ± 1.75 mm preoperatively to 14.8 ± 1.79 mm postoperatively in the endoscopic medial wall and transconjunctival inferior wall approach group. Postoperative complications occurred in 2 patients who displayed periphery diplopia, in the endoscopic medial wall and transconjunctival inferior wall approach group. A survey to assess the level of cosmetic satisfaction was significantly improved in both groups after surgery.

CONCLUSION

Endoscopic medial wall decompression is an approach that achieves sufficient orbital decompression while minimizing complications.

Evaluation of Quality of Life in the Brazilian Graves' Disease Population: Focus on Mild and Moderate Graves' Orbitopathy Patients

Background: Quality of life (QoL) studies in patients with mild to moderate Graves' orbitopathy (GO) are scarce. Methods: The original GO-QoL questionnaire was translated to Portuguese and administered to 323 patients with Graves' disease. The clinically active score (CAS) was used to evaluate GO activity, and the NO SPECS and EUGOGO classifications were used to estimate GO severity. Results: The internal consistency of the GO-QoL, evaluated using Cronbach's alpha, was optimal. In people with Graves' disease and long-duration GO, both visual function and appearance scores were negatively associated with the CAS and NOSPECS and EUGOGO classifications (P < 0.001). Asymmetry and proptosis were significantly associated with the visual function and appearance domains, and diplopia was related to the visual function score. In addition, multivariate regression stepwise analysis revealed that disease severity, according to the EUGOGO classification, was associated with the visual function and appearance scores; asymmetry, presence of proptosis, and young age were associated with the appearance score (P < 0.001). The visual function and appearance scores were negatively correlated with the CAS and NOSPECS and EUGOGO classifications (P < 0.001). Conclusion: Graves' orbitopathy has a negative impact in QoL in patients with mild to moderate disease, even after an extended period, rendering GO a chronic disease. The GO-QoL questionnaire can be helpful in identifying patients in need of attention and support.

Development and Validation of the Singapore Thyroid Eye Disease Quality of Life Questionnaire

Purpose

Current instruments to assess thyroid eye disease (TED) quality of life (QoL) were not developed using modern psychometric theory and may not be applicable to Asian populations. Therefore, we developed a psychometrically robust questionnaire, the Singapore Thyroid Eye Disease Quality of Life questionnaire (STED-QoL), for assessing QoL in Asian patients.

Methods

This cross-sectional study was conducted at the Singapore National Eye Centre between 2012 and 2015. In Phase 1, content for the questionnaire was developed using qualitative methods. A total of 20 patients participated in three different focus groups. Thematic analysis was conducted to identify relevant themes from which 12 items, rated on a 5-point Likert-type scale, were generated. In Phase 2, the pilot instrument was administered to 59 TED patients and psychometric assessment of the STED-QoL was conducted using Rasch analysis.

Results

After collapsing categories from five to four and deleting two misfitting items, we generated a 10-item STED-QoL befitting the Rasch model. The scale showed good criterion validity, with scores decreasing as severity of TED worsened: mild (1.78 logits), moderate (0.27 logits), and severe (0.92 logits). A ‘Psychosocial' subscale also had adequate psychometric properties and psychosocial scores were significantly worse in those who underwent surgery for TED compared to those who had not (0.41 vs. 1.82 logits, P = 0.021).

Conclusions

The STED-QoL is a robust 10-item questionnaire specifically developed to measure the impact of TED on QoL and psychosocial well-being in an Asian population.

Translational Relevance

QoL assessment is important for holistic management of TED patients.

Objectively Measuring Observer Attention in Severe Thyroid-Associated Orbitopathy: A 3D Study

OBJECTIVE

Measure the attentional distraction of facial deformity related to severe thyroid-associated orbitopathy using three-dimensional (3D) images and eye-tracking technology.

METHODS

Observers recruited at an academic tertiary referral center viewed 3D facial images of patients with severe thyroid-associated orbitopathy (TAO) and controls without TAO. An infrared eye-tracking monitor recorded their eye movements and fixations in real time. Multivariate Hotelling's analysis, followed by planned posthypothesis testing, was used to compare fixation durations for predefined regions of interest, including the eyes, nose, mouth, central triangle, and remaining face without the central triangle between severe TAO patients and controls.

RESULTS

One hundred sixteen observers (mean age 26.4 years, 51% female) successfully completed the eye-tracking experiment. The majority of their attention was directed toward the central triangle (eyes, nose, mouth). On multivariate analysis, there were significant differences in the distribution of attention between control and severe TAO faces (T²  = 49.37; F(5,922) = 9.8314, P < 0.0001). On planned posthypothesis testing, observers attended significantly more to the eyes (0.77 seconds, P < 0.0001, 95% confidence interval [CI], 0.51, 1.03 seconds) and less to the nose (-0.42 seconds, P < 0.0001, 95% CI, -0.23, -0.62 seconds) in severe TAO patients. There was no significant difference in time spent on the mouth, the total time spent on the central triangle, or time spent in the remaining face between the two groups.

CONCLUSION

Severe TAO distracted observer attention toward the eyes compared to control patients. These data lend insight into how TAO may alter observers' perceptions of these patients. Future studies should investigate how these changes in observer gaze patterns may reflect the social perception of TAO patients.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:1250-1254, 2019.

Surgical outcomes of unilateral recession-resection for vertical strabismus in patients with thyroid eye disease

PURPOSE

To present the surgical outcomes of vertical muscle resection in patients with thyroid eye disease (TED).

METHODS

The medical records of 6 patients who underwent unilateral vertical muscle recession-resection to correct vertical strabismus in TED were reviewed retrospectively for postoperative angle of vertical deviation on days 1 and 7 and at months 1, 3, 6, and 12. Surgery was considered successful if the vertical deviation was ≤4^Δ. Reoperation rates and complications were also noted.

RESULTS

The mean preoperative angle of vertical deviation was 39.2^Δ ± 3.8^Δ, and the mean final ocular deviation at 12 months postoperatively was 3.8^Δ ± 5.9^Δ. There was significant reduction in postoperative vertical deviation (paired t test, P < 0.001). Surgery was successful in 4 patients (67%). There was neither unusual postoperative inflammation nor increased restriction of the resected muscle postoperatively in any patient.

CONCLUSIONS

Based on careful assessment and appropriate patient selection, vertical muscle resection can be considered an effective option that provides satisfactory surgical outcomes with regard to vertical deviation correction in TED.

[Endocrine ophthalmopathy. A visible psychophysical complaint]

BACKGROUND

Endocrine orbitopathy (Graves' disease) is an autoimmune disease based on a genetic predisposition. Patients with a visible exophthalmos were examined and treated in the department of ophthalmology.

OBJECTIVES

Is there an association between the formation of exophthalmos and life situations and events?

MATERIAL AND METHODS

A total of 64 patients with exophthalmos due to Graves' disease were asked to complete a questionnaire to evaluate psychosocial morbidity, the quality of life, social background and stressful life events.

RESULTS

The results revealed that 60% of the participants had experienced stressful life events (e.g. workplace, parents, children and partner), mainly bereavement in the months before onset of the disease. The psychosocial background revealed that they were predominantly from a low social status and lived in unsatisfactory employment, partner and environmental conditions.

CONCLUSION

Graves' disease is an autoimmune disease and is substantially triggered by psychosocial factors. The necessary interdisciplinary therapy should include medical psychotherapy.

Intraorbital injection of rituximab versus high dose of systemic glucocorticoids in the treatment of thyroid-associated orbitopathy

The aim of the study was to compare, in a randomized prospective study, the efficacy and safety of intraorbital administration of low doses of RTX versus intravenous glucocorticoids (GCs) to treat patients affected by moderately severe thyroid-associated active orbitopathy. Twenty patients with active, moderately severe TAO, whose mean age was 56.7 years±10.2 SD participated in the study. Patients were randomly selected and treated with intraorbital injections of RTX or with i.v. GCs. Disease activity and severity were assessed by the Clinical Activity Score (CAS) and the NOSPECS. Computed tomography or magnetic resonance scans were performed in all patients. In the RTX group, full blood cell count and flow cytometric analysis on peripheral blood lymphocytes were done. The patients were followed for 20 months. In both groups, CAS and NOSPECS indexes were significantly reduced (p<0.005). In particular, CAS reduction was evident since the first follow-up with both treatments. Proptosis decreased significantly only in group B and diplopia showed no significant changes during follow-up times in both groups. Neither of the treatments affected the peripheral TRab. In group A, 5 weeks after the first injection, the CD20+ peripheral lymphocytes value was nearly zero. One patient treated with rituximab progressed to severe TAO (optic neuropathy) following the second injection so the treatment was discontinued. The data confirm the therapeutic efficacy of RTX in active TAO, even in low doses and locally administered. The efficacy on the inflammatory component of the disease is comparable to that of steroids and seems to be related with the reduction of peripheral CD20+ lymphocytes. Caution should be given to an accurate patient selection.

Risk of developing depressive disorders following rheumatoid arthritis: a nationwide population-based study

Background & Aims

To evaluate the risk of depressive disorders among rheumatoid arthritis (RA) by using the Taiwan National Health Insurance Research Database (NHIRD).

Methods

We conducted a retrospective study of a matched cohort of 18 285 participants (3 657 RA patients and 14 628 control patients) who were selected from the NHIRD. Patients were observed for a maximum of 10 years to determine the rates of newly diagnosed depressive disorders, and Cox regression was used to identify the risk factors associated with depressive disorders in RA patients.

Results

During the 10-year follow-up period, 205 (11.2 per 1000 person-years) RA patients and 384 (5.1 per 1000 person-years) control patients were diagnosed with depressive disorders. In RA patients, most depressive disorders (n = 163, 80%) developed with five years of being diagnosed with RA. The incidence risk ratio of depressive disorders between RA patients and control patients was 2.20 (95% confidence interval [CI], 1.84–2.61, P<.001). After adjusting for age, sex, and comorbidities, RA patients were 2.06 times more likely to develop depressive disorders (95% CI, 1.73–2.44, P<.001) compared with the control patients. Hyperthyroidism (HR = 1.67) was an independent risk factor for depressive disorders in patients with RA.

Conclusions

The likelihood of developing depressive disorders is greater among RA patients than among patients without RA. Symptoms of depression should be sought in patients with RA.

Measuring quality of life in oculoplastic patients

AIM

To investigate if there is any published evidence of impaired quality of life in conditions which are corrected by oculoplastic surgery and whether there is proven benefit in the quality of life such procedures.

METHODS

We searched a number of databases to determine the level of evidence available for common conditions amenable to oculoplastic surgery. Search terms concentrated on quality of life measures rather than anatomical correction of deformities.

RESULTS

The level of evidence available for different conditions was very variable. Certain conditions had extensive research documenting reduction in quality of life, with some evidence for improvement after surgery. Some other common conditions had little or no evidence supporting of reduction in quality of life to support the need for surgery.

CONCLUSION

The evidence is sparse for quality of life improvement after some of our most commonly performed procedures. Many of these procedures are now being identified by primary care trusts (PCTs) as of "low clinical value", and are no longer being routinely commissioned in certain parts of the UK. There is a need to address this lack of evidence to determine whether oculoplastic surgery should continue to be commissioned by PCTs.

Determinants of quality of life in patients with skull base chordoma

Object

Skull base chordomas can be managed by surgical intervention and adjuvant radiotherapy. As survival for this disease increases, identification of determinants of quality of life becomes an important focus for guiding comprehensive patient care. In this study the authors sought to measure functional outcome and quality of life in patients with skull base chordomas and to identify determinants of quality of life in these patients.

Methods

The authors carried out an internet-based cross-sectional survey, collecting detailed data for 83 individual patients. Demographic and clinical variables were evaluated. Functional outcomes were determined by Karnofsky Performance Scale (KPS) and Glasgow Outcome Scale Extended (GOSE), quality of life was measured using the 36-Item Short Form Health Survey (SF-36), and depression was assessed using Patient Health Questions–9 (PHQ-9) instrument. Caregiver burden was assessed using the Zarit Burden Interview (ZBI). Univariate and multivariate analysis was performed to identify determinants of the physical and mental components of the SF-36.

Results

Patients with skull base chordomas who have undergone surgery and/or radiation treatment had a median KPS score of 90 (range 10–100, IQR 10) and a median GOSE score of 8 (range 2–8, IQR 3). The mean SF-36 Physical Component Summary score (± SD) was 43.6 ± 11.8, the mean Mental Component Summary score was 44.2 ±12.6, and both were significantly lower than norms for the general US population (p < 0.001). The median PHQ-9 score was 5 (range 0–27, IQR 8). A PHQ-9 score of 10 or greater, indicating moderate to severe depression, was observed in 29% of patients. The median ZBI score was 12 (range 0–27, IQR 11), indicating a low burden. Neurological deficit, use of pain medication, and requirement for corticosteroids were found to be associated with worse SF-36 Physical Component Summary score, while higher levels of depression (higher PHQ-9 score) correlated with worse SF-36 Mental Component Summary score.

Conclusions

Patients with skull base chordomas have a lower quality of life than the general US population. The most significant determinants of quality of life in the posttreatment phase in this patient population were neurological deficits (sensory deficit and bowel/bladder dysfunction), pain medication use, corticosteroid use, and levels of depression as scored by PHQ-9.

Rectus muscle resection in Graves' ophthalmopathy

BACKGROUND

In the treatment of Graves' ophthalmopathy, rectus muscle resections generally are avoided because of the concern of reaggravating inflammation and creating excessive extraocular muscle restriction. In patients with large-angle strabismus and in patients with residual strabismus after maximal recession surgery, however, rectus muscle resection may be considered. We report a series of 8 patients with Graves' ophthalmopathy who underwent rectus muscle resections.

METHODS

The records of 270 patients with Graves' ophthalmopathy who had undergone strabismus surgery were retrospectively reviewed. Data from subjects who had undergone rectus muscle resections were collected, including age at surgery, duration of disease, duration of diplopia, previous eye or strabismus surgeries, history of radioactive iodine or corticosteroid treatment, current thyroid medications, current use of corticosteroids, tobacco use, and signs and symptoms used to diagnose Graves' ophthalmopathy.

RESULTS

Eight patients (5 females) were identified (mean age, 51.1 ± 17.6 years). Preoperatively, 4 patients had a horizontal deviation and 4 patients had both horizontal and vertical deviations in primary gaze. Mean preoperative horizontal deviation was 27.9(Δ) ± 15.2(Δ) and mean vertical deviation was 6.3(Δ) ± 5.4(Δ). At final follow-up examination, 7 patients were orthotropic in primary gaze; 1 patient had a larger deviation from slippage as the result of a broken suture within the first postoperative week. None of the patients were overcorrected or developed atypical inflammation.

CONCLUSIONS

In this series, patients with Graves' ophthalmology were successfully treated with the use of rectus muscle resections as part of the surgical plan. Careful ocular motility assessment and patient selection is critical if this option is contemplated.

Treatment of upper eyelid retraction related to thyroid-associated ophthalmopathy using subconjunctival triamcinolone injections

BACKGROUND

To evaluate the efficacy of subconjunctival triamcinolone injection for treating upper eyelid retraction caused by thyroid-associated ophthalmopathy (TAO).

METHODS

Prospective single blind randomized clinical trial. Patients diagnosed with TAO-associated eyelid retraction and/or swelling <6 months before study onset were randomly assigned to triamcinolone-injected (group I; 55 patients, 75 eyes) or observation-only (group II; 40 patients, 59 eyes) populations. Group I received 1-3 injections of 20 mg triamcinolone acetate into the subconjunctival eyelid, between the conjunctiva and Muller's muscle, at 3-week intervals. Group I was followed up at 3, 6, 9, and 24 weeks post-injection, and group II was evaluated at 9 and 24 weeks after initial visit. Eyelid swelling and retraction were each graded on a 0-3 scale. Treatment was stopped after 1-2 injections if both swelling and retraction resolved completely or if retraction and swelling scored 0/1 or 1/0 without functional or cosmetic patient concerns. Treatment success was defined at 9 and 24 weeks post-injection if eyelids were normal or when treatment was terminated because of early clinical resolution. We compared baseline clinical data between success and failure group evaluated at 9 and 24 weeks in group I, and investigated short-term and long-term success prognostic factor using multiple logistic regression analysis in each group I and II.

RESULTS

Swelling and retraction decreased significantly more in group I than in group II. Significantly more eyes had severe swelling (≥ grade 2) in group I (67 %) than in group II (34 %) upon initial evaluation (p < 0.01); this difference disappeared at 9 and 24 weeks. Fewer severely retracted eyes were observed in group I than in group II at 9 and 24 weeks (p < 0.01). Significantly more eyes in group I achieved success at both 9 and 24 weeks (59 %, 75 %) than in group II (39 %, 57 %) (p = 0.03, p = 0.04 respectively). Higher initial retraction grades (2-3) predicted a higher chance of post-injection failure versus the reference group (grade 0-1) at 9 and 24 weeks in group I, with adjusted odds ratios (aOR) 45.4 (95 % CI = 5.9-351.1, p < 0.01) and aOR 11.6 (95 % CI = 2.3-58.5, p < 0.01) respectively. Similarly in group II, initial retraction grade was associated with the failure at 9 and 24 weeks, with aOR 10.3 (95 % CI = 1.8-59.6, p < 0.01) and aOR 5.9 (95 % CI = 1.3-25.9, p < 0.05) respectively. Transient intraocular pressure elevation was observed in three eyes of two patients, although all ocular pressures were normalized within 1 month using anti-glaucoma medication.

CONCLUSIONS

Subconjunctival triamcinolone injections were very effective in resolving eyelid swelling and retraction in recent-onset TAO. However, the symptom-reducing effect of triamcinolone was modest and less effective in patients initially presenting with severe retraction grades. As intraocular pressure may rise after steroid injection at upper eyelid, the treatment should be avoided in patients suspected to have glaucoma.

Quality of life in Graves' ophthalmopathy

General health-related quality-of-life (QoL) questionnaires (MOS SF-24 and SF-36) and the more sensitive disease-specific QoL questionnaire (GO-QoL) both indicate substantial impairment of quality of life in patients with Graves' ophthalmopathy (GO). The GO-QoL contains 8 questions on visual functioning and 8 questions on appearance; answers on each subscale are transformed to scores ranging from 0 (worst) to 100 (best). The minimal clinically important difference in scores is ≥10 points for invasive therapies, but a change of 6 points on one of both subscales is already perceived by patients as beneficial and associated with an important change in daily functioning. The GO-QoL is well validated, widely used, and available in eight languages. The GO-QoL is recommended as an independent primary outcome measure in randomized clinical trials. Incorporating the GO-QoL in the routine assessment of GO in daily clinical practice is also recommended: although unproven, it is likely to improve the quality of care by identifying patients who are in need for psychological support in order to address poor psychosocial functioning and low self-esteem.

Assessing Graves' ophthalmopathy-specific quality of life in Korean patients

AIM

To investigate the clinical significance of Grave's ophthalmopathy-specific quality of life (GO-QOL) in Korean patients.

METHODS

A cross-sectional study was conducted at the Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea, on 98 consecutive Grave's ophthalmopathy (GO) patients. The GO-QOL survey provided by Terwee and colleagues and suggested by the European group on Graves' orbitopathy (EUGOGO) was translated into Korean language and distributed to study participants. Clinical severity was judged by scores of the modified NOSPECS classification, and inflammatory activity was measured by a seven-point scale of clinical activity score (CAS).

RESULTS

The mean GO-QOL scores were 73.7 (standard deviation (SD), 26) for visual functioning, 61.9 (SD 26) for appearance, and 67.8 for total quality of life (QOL; SD 22). The worse QOL scores for each part were significantly associated with the higher modified NOSPECS score and CAS after adjusting for confounders such as age and sex (P<0.05, respectively). In particular, decreased QOL scores for visual function were significantly correlated with a higher grade of extraocular muscle involvement (P<0.05). Lower QOL scores for appearance were associated with more severe soft-tissue involvement and proptosis (P<0.05, respectively).

CONCLUSIONS

GO-QOL suggested by EUGOGO showed correlation with objective clinical parameters. GO-QOL can be a simple and effective tool in the evaluation of the clinical and psychological illness of GO patients.

Quality of life in thyroid eye disease: impact of quality of care

Thyroid eye disease (TED) is a chronic debilitating condition causing physical discomfort, facial disfigurement and impaired visual function. The physical consequences of TED could have a negative and lasting impact on patients' employment, hobbies and psychosocial function. In this review, we assess the evidence of the impact of TED on patients' quality of life (QOL) and also explore the effects of suboptimal quality of care on QOL of patients with this disease. It is hoped that recent initiatives, including the Amsterdam declaration, to raise the quality of care for patients with TED will help to improve their QOL.