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Le Moli R, Naselli A, Costanzo G, Piticchio T, Tumino D, Pellegriti G, Frasca F, Belfiore A. Determinants of clinical outcome in patients with moderate/severe Graves' orbitopathy undergoing treatment with parenteral glucocorticoids: a retrospective study. Front Endocrinol (Lausanne) 2024; 15:1401155. [PMID: 39027472 PMCID: PMC11254611 DOI: 10.3389/fendo.2024.1401155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/17/2024] [Indexed: 07/20/2024] Open
Abstract
Background Graves' orbitopathy (GO) occurs in approximately 25-40% of patients with Graves' disease (GD). High levels of anti-thyrotropin receptor antibodies (TRAbs), smoking habit, sex, older age, longer duration and amount of hyperthyroidism or hypothyroidism are well-recognized risk factors for the occurrence, severity and clinical course of GO. Oxidative stress (OX) has recently been shown to play a role in the pathogenesis of GO, and several clinical conditions related to OX have been investigated regarding the presentation and severity of GO. Aim We aimed to evaluate the impact of clinical conditions related to oxidative stress on the outcome of intravenous glucocorticoid (ivGCs) therapy in a cohort of patients with active moderate to severe GO (AMS-GOs) treated at a single institution. Methods We retrospectively studied a series of patients with AMS-GOs who were treated with ivGCs from January 2013 to May 2022. GO clinical evaluation was performed at baseline and at 6 (W6), 12 (W12) and 24 (W24) weeks after starting ivGCs by the seven-point clinical activity score (CAS) alone and by overall clinical criteria (CI) according to the European Group of Graves' Ophthalmopathy (EUGOGO). Total cholesterol and calculated LDL cholesterol (LDLc), triglyceride, body mass index (BMI), diabetes status, history of hypertension (HoH), smoking status, age and sex were used as covariates for the clinical outcome of GO to ivGCs. Results and conclusions LDLc and HoH negatively and independently modulated the response of AMS-GOs to ivGCs. Notably, slightly elevated LDLc levels (> 130 mg/dl) reduced the response of orbital soft tissue to ivGCs, whereas more elevated LDLc levels (from 175 mg/dl to 190 mg/dl) and HoH were associated with poorer clinical response of eye motility and proptosis.
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Affiliation(s)
- Rosario Le Moli
- Endocrinology Unit, Department of Clinical and Experimental Medicine, Garibaldi Nesima Hospital, University of Catania, Catania, Italy
- Department of Medicine and Surgery, University of Enna "Kore", Enna, Italy
| | - Adriano Naselli
- Endocrinology Unit, Department of Clinical and Experimental Medicine, Garibaldi Nesima Hospital, University of Catania, Catania, Italy
| | - Gabriele Costanzo
- Endocrinology Unit, Department of Clinical and Experimental Medicine, Garibaldi Nesima Hospital, University of Catania, Catania, Italy
| | - Tommaso Piticchio
- Endocrinology Unit, Department of Clinical and Experimental Medicine, Garibaldi Nesima Hospital, University of Catania, Catania, Italy
- Department of Medicine and Surgery, University of Enna "Kore", Enna, Italy
| | - Dario Tumino
- Endocrinology Unit, Department of Clinical and Experimental Medicine, Garibaldi Nesima Hospital, University of Catania, Catania, Italy
| | - Gabriella Pellegriti
- Endocrinology Unit, Department of Clinical and Experimental Medicine, Garibaldi Nesima Hospital, University of Catania, Catania, Italy
| | - Francesco Frasca
- Endocrinology Unit, Department of Clinical and Experimental Medicine, Garibaldi Nesima Hospital, University of Catania, Catania, Italy
| | - Antonino Belfiore
- Endocrinology Unit, Department of Clinical and Experimental Medicine, Garibaldi Nesima Hospital, University of Catania, Catania, Italy
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Oeverhaus M, Neumann I, Chen Y, Eckstein A. [Graves' orbitopathy as the cause of diplopia in old age-Differences between young and old]. DIE OPHTHALMOLOGIE 2024; 121:548-553. [PMID: 38922402 DOI: 10.1007/s00347-024-02073-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Endocrine orbitopathy (EO) is an autoimmune disease mostly associated with a disease of the thyroid gland, which leads to inflammation, adipogenesis and fibrosis. The severity of EO can vary greatly between individuals, which makes it difficult to exactly predict the natural course of the disease; however, this is important to be able to individually adapt the treatment. The aim of this study was to compare the clinical features, course, treatment and prognosis for patients with EO under 50 years old with older patients. The results of the study with a focus on motility are presented in this special issue. PATIENTS AND METHODS The hospital records of a randomly selected sample of 1000 patients from the EO databank in Essen (GODE), which includes 4260 patients, were analyzed. The patients were divided into two groups: group 1 ≤50 years and group 2 >50 years. Only patients with complete data sets were included in the statistical analyses. RESULTS Younger patients (n = 484) presented significantly more frequently with milder EO (53% vs. 33%, p < 0.0001), whereas older patients (n = 448) more frequently suffered from moderate or severe forms (44% vs. 64%, p < 0.0001). Older patients showed more severe strabismus, motility and clinical activity scores (5.9 vs. 2.3 prism diopters, PD/310° vs. 330°, both p < 0.0001, CAS 2.1 vs. 1.7, p = 0.001). Proptosis and the occurrence of optic nerve compression showed no significant differences between the groups (3% each). Multiple logistic regression showed that the necessity for a second eye muscle surgery was most strongly associated with a previous decompression (OR = 0.12, 95 % CI 0.1-0.2, p < 0.0001), followed by orbital irradiation and age. CONCLUSION In summary, younger patients with EO presented with milder clinical features, such as a lower rate of restrictive motility disorders and weaker expression of signs of inflammation. Therefore, older patients needed steroids, irradiation, eyelid and eye muscle surgery more frequently; however, the risk of dysthyroid optic neuropathy and the necessity of a second eye surgery were not or only slightly associated with age.
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Affiliation(s)
- Michael Oeverhaus
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| | - Inga Neumann
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| | - Ying Chen
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| | - Anja Eckstein
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland
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Hedergott A, Fricke J, Roggenkämper B, Gietzelt C, Grandoch A, Neugebauer A. [Differential diagnosis of vertical strabismus in the elderly]. DIE OPHTHALMOLOGIE 2024; 121:529-539. [PMID: 38904722 DOI: 10.1007/s00347-024-02072-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/11/2024] [Indexed: 06/22/2024]
Abstract
Due to the demographic changes, the number of older patients in ophthalmological practices and clinics, including those with diplopia, is increasing. Some of the patients report not only horizontally shifted double images but also or only vertically shifted double images. Vertical double vision often causes significant diagnostic problems for ophthalmologists. The underlying condition could urgently require further neurological, neuroradiological and/or internal medical diagnostics (e.g., skew deviation, 4th nerve palsy, myasthenia, Graves' orbitopathy, orbital floor fracture, orbital mass, 3rd nerve palsy) but the cause of diplopia could also be a condition in which overdiagnosis should be avoided (e.g., sagging eye syndrome, the prevalence of which significantly increases with increasing age; decompensated strabismus due to inferior oblique muscle overaction, myopia-associated vertical tropia). For some diseases early diagnosis is important for a better prognosis, e.g., tumor diagnosis, Graves' disease and stroke. This article presents an overview of the most common and most important differential diagnoses of vertical tropia in patients over 50 years of age.
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Affiliation(s)
- Andrea Hedergott
- Zentrum für Augenheilkunde, Universitätsklinikum Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - Julia Fricke
- Zentrum für Augenheilkunde, Universitätsklinikum Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Bettina Roggenkämper
- Zentrum für Augenheilkunde, Universitätsklinikum Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Caroline Gietzelt
- Zentrum für Augenheilkunde, Universitätsklinikum Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Andrea Grandoch
- Klinik und Poliklinik für Mund‑, Kiefer- und Plastische Gesichtschirurgie, Poliklinik für Orale Chirurgie und Implantologie, Plastische, rekonstruktive und ästhetische Chirurgie, Universitätsklinikum Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Antje Neugebauer
- Zentrum für Augenheilkunde, Universitätsklinikum Köln, Kerpener Str. 62, 50937, Köln, Deutschland
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Eckstein A, Welkoborsky HJ. [Interdisciplinary Management of Orbital Diseases]. Laryngorhinootologie 2024; 103:S43-S99. [PMID: 38697143 DOI: 10.1055/a-2216-8879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
Diagnosis and therapy of orbital diseases is an interdisciplinary challenge, in which i.e. otorhinolaryngologists, ophthalmologists, radiologists, radiation therapists, maxillo-facial surgeons, endocrinologists, and pediatricians are involved. This review article describes frequent diseases which both, otolaryngologists and ophthalmologists are concerned with in interdisciplinary settings. In particular the inflammatory diseases of the orbit including orbital complications, autoimmunological diseases of the orbit including Grave´s orbitopathy, and primary and secondary tumors of the orbit are discussed. Beside describing the clinical characteristics and diagnostic steps the article focusses on the interdisciplinary therapy. The review is completed by the presentation of most important surgical approaches to the orbit, their indications and possible complications. The authors tried to highlight the relevant facts despite the shortness of the text.
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Affiliation(s)
| | - H-J Welkoborsky
- Univ. Klinik für Augenheilkunde Universitätsmedizin Essen, Klinik für HNO-Heilkunde, Kopf- und Halschirurgie, Klinikum Nordstadt der KRH
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Buonfiglio F, Ponto KA, Pfeiffer N, Kahaly GJ, Gericke A. Redox mechanisms in autoimmune thyroid eye disease. Autoimmun Rev 2024; 23:103534. [PMID: 38527685 DOI: 10.1016/j.autrev.2024.103534] [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: 01/12/2024] [Revised: 03/20/2024] [Accepted: 03/22/2024] [Indexed: 03/27/2024]
Abstract
Thyroid eye disease (TED) is an autoimmune condition affecting the orbit and the eye with its adnexa, often occurring as an extrathyroidal complication of Graves' disease (GD). Orbital inflammatory infiltration and the stimulation of orbital fibroblasts, triggering de novo adipogenesis, an overproduction of hyaluronan, myofibroblast differentiation, and eventual tissue fibrosis are hallmarks of the disease. Notably, several redox signaling pathways have been shown to intensify inflammation and to promote adipogenesis, myofibroblast differentiation, and fibrogenesis by upregulating potent cytokines, such as interleukin (IL)-1β, IL-6, and transforming growth factor (TGF)-β. While existing treatment options can manage symptoms and potentially halt disease progression, they come with drawbacks such as relapses, side effects, and chronic adverse effects on the optic nerve. Currently, several studies shed light on the pathogenetic contributions of emerging factors within immunological cascades and chronic oxidative stress. This review article provides an overview on the latest advancements in understanding the pathophysiology of TED, with a special focus of the interplay between oxidative stress, immunological mechanisms and environmental factors. Furthermore, cutting-edge therapeutic approaches targeting redox mechanisms will be presented and discussed.
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Affiliation(s)
- Francesco Buonfiglio
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
| | - Katharina A Ponto
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
| | - Norbert Pfeiffer
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
| | - George J Kahaly
- Medicine I (GJK), University Medical Center of the Johannes Gutenberg- University, Mainz, Germany.
| | - Adrian Gericke
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
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Wang M, Li G, Dong L, Hou Z, Zhang J, Li D. Severity Identification of Graves Orbitopathy via Random Forest Algorithm. Horm Metab Res 2024. [PMID: 38588699 DOI: 10.1055/a-2287-3734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
This study aims to establish a random forest model for detecting the severity of Graves Orbitopathy (GO) and identify significant classification factors. This is a hospital-based study of 199 patients with GO that were collected between December 2019 and February 2022. Clinical information was collected from medical records. The severity of GO can be categorized as mild, moderate-to-severe, and sight-threatening GO based on guidelines of the European Group on Graves' orbitopathy. A random forest model was constructed according to the risk factors of GO and the main ocular symptoms of patients to differentiate mild GO from severe GO and finally was compared with logistic regression analysis, Support Vector Machine (SVM), and Naive Bayes. A random forest model with 15 variables was constructed. Blurred vision, disease course, thyroid-stimulating hormone receptor antibodies, and age ranked high both in mini-decreased gini and mini decrease accuracy. The accuracy, positive predictive value, negative predictive value, and the F1 Score of the random forest model are 0.83, 0.82, 0.86, and 0.82, respectively. Compared to the three other models, our random forest model showed a more reliable performance based on AUC (0.85 vs. 0.83 vs. 0.80 vs. 0.76) and accuracy (0.83 vs. 0.78 vs. 0.77 vs. 0.70). In conclusion, this study shows the potential for applying a random forest model as a complementary tool to differentiate GO severity.
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Affiliation(s)
- Minghui Wang
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Beijing Ophthalmology and Visual Science Key Lab, Beijing, China
- Department of Ophthalmology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Gongfei Li
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany
| | - Li Dong
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Beijing Ophthalmology and Visual Science Key Lab, Beijing, China
| | - Zhijia Hou
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Beijing Ophthalmology and Visual Science Key Lab, Beijing, China
| | - Ju Zhang
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Beijing Ophthalmology and Visual Science Key Lab, Beijing, China
| | - Dongmei Li
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Beijing Ophthalmology and Visual Science Key Lab, Beijing, China
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Oeverhaus M, Sander J, Smetana N, Bechrakis NE, Inga N, Al-Ghazzawi K, Chen Y, Eckstein A. How Age Affects Graves' Orbitopathy-A Tertiary Center Study. J Clin Med 2024; 13:290. [PMID: 38202297 PMCID: PMC10779662 DOI: 10.3390/jcm13010290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/08/2023] [Accepted: 11/29/2023] [Indexed: 01/12/2024] Open
Abstract
PURPOSE Graves' orbitopathy (GO) is an autoimmune disorder leading to inflammation, adipogenesis, and fibrosis. The severity of GO can vary widely among individuals, making it challenging to predict the natural course of the disease accurately, which is important for tailoring the treatment approach to the individual patient. The aim of this study was to compare the clinical characteristics, course, treatment, and prognosis of GO patients under 50 years with older patients. METHODS We reviewed the medical records of a random sample of 1000 patients in our GO database Essen (GODE) comprising 4260 patients at our tertiary referral center. Patients were divided into two groups: Group 1 (≤50 years) and Group 2 (>50 years). Only patients with a complete data set were included in the further statistical analysis. RESULTS The results showed that younger patients (n = 484) presented significantly more often with mild GO (53% vs. 33%, p < 0.0001), while older patients (n = 448) were more likely to experience moderate-to-severe disease (44% vs. 64%, p < 0.0001). Older patients showed more severe strabismus, motility, and clinical activity scores (5.9 vs. 2.3 PD/310° vs. 330° both p < 0.0001, CAS: 2.1 vs. 1.7, p = 0.001). Proptosis and occurrence of dysthyroid optic neuropathy (DON) showed no significant difference between groups (both 3%). Multiple logistic regression revealed that the need for a second step of eye muscle surgery was most strongly associated with prior decompression (OR = 0.12, 95% CI: 0.1-0.2, p < 0.0001) followed by orbital irradiation and age. The model showed good fitness regarding the area under the curve (AUC = 0.83). DISCUSSION In conclusion, younger GO patients present with milder clinical features such as a lower rate of restrictive motility disorders and less pronounced inflammatory signs. Therefore, older patients tend to need more steroids, irradiation, and lid and eye muscle surgery. Still, the risk of DON and the necessity of secondary eye muscle surgery are not or only slightly associated with age, respectively.
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Affiliation(s)
- Michael Oeverhaus
- Department of Ophthalmology, University Hospital Essen, 45147 Essen, Germany
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Eckstein A, Stöhr M, Görtz GE, Gulbins A, Möller L, Fuehrer-Sakel D, Oeverhaus M. Current Therapeutic Approaches for Graves' Orbitopathy - are Targeted Therapies the Future? Klin Monbl Augenheilkd 2024; 241:48-68. [PMID: 37799096 DOI: 10.1055/a-2186-5548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Graves' orbitopathy is an autoimmune disease of the orbit that most frequently occurs with Graves' hyperthyroidism. The occurrence of autoantibodies directed against the TSH receptor (TRAb) is of central importance for the diagnosis and pathogenesis. These autoantibodies are mostly stimulating, and induce uncontrolled hyperthyroidism and tissue remodelling in the orbit and more or less pronounced inflammation. Consequently, patients suffer to a variable extent from periocular swelling, exophthalmos, and fibrosis of the eye muscles and thus restrictive motility impairment with double vision. In recent decades, therapeutic approaches have mainly comprised immunosuppressive treatments and antithyroid drug therapy for hyperthyroidism to inhibit thyroid hormone production. With the recognition that TRAb also activates an important growth factor receptor, IGF1R (insulin-like growth factor 1 receptor), biological agents have been developed. Teprotumumab (an inhibitory IGF1R antibody) has already been approved in the USA and the therapeutic effects are enormous, especially with regard to the reduction of exophthalmos. Side effects are to be considered, especially hyperglycaemia and hearing loss. It is not yet clear whether the autoimmune reaction (development of the TRAb/attraction of immunocompetent cells) is also influenced by anti-IGF1R inhibiting agents. Recurrences after therapy show that the inhibition of antibody development must be included in the therapeutic concept, especially in severe cases.
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Affiliation(s)
- Anja Eckstein
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Deutschland
| | - Mareile Stöhr
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Deutschland
| | - Gina-Eva Görtz
- Labor für Molekulare Augenheilkunde, Universität Duisburg-Essen, Duisburg, Deutschland
| | - Anne Gulbins
- Labor für Molekulare Augenheilkunde, Universität Duisburg-Essen, Duisburg, Deutschland
| | - Lars Möller
- Klinik für Endokrinologie, Diabetologie und Stoffwechsel, Universitätsklinikum Essen, Deutschland
| | - Dagmar Fuehrer-Sakel
- Klinik für Endokrinologie, Diabetologie und Stoffwechsel, Universitätsklinikum Essen, Deutschland
| | - Michael Oeverhaus
- Klinik für Augenheilkunde, Universitätsklinikum Essen, Deutschland
- Gemeinschaftspraxis Dres. Oeverhaus & Weiß, Rietberg, Deutschland
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