A Prospective, Randomized, Double-blind, Placebo-controlled Study of Orbital Radiotherapy for Graves' Ophthalmopathy

CONTEXT

Although widely used for more than 85 years, the efficacy of radiotherapy for Graves' ophthalmopathy (GO) has not been established convincingly.

OBJECTIVE

To evaluate the efficacy of radiotherapy for GO.

DESIGN

Prospective, randomized, internally controlled, double-blind clinical trial in a tertiary care academic medical center.

PARTICIPANTS

The patients were ethnically diverse males and females over age 30 seen in a referral practice. The patients had moderate, symptomatic Graves' ophthalmopathy (mean clinical activity score, 6.2) but no optic neuropathy, diabetes, recent steroid treatment, previous decompression, or muscle surgery. Forty-two of 53 consecutive patients were enrolled after giving informed consent and fulfilling study entry criteria. Eleven eligible patients declined to participate because of inconvenience, desire for alternative therapy, or concern about radiation.

INTERVENTION

One randomly selected orbit was treated with 20 Gy of external beam therapy; sham therapy was given to the other side. Six months later, the therapies were reversed.

MAIN OUTCOME MEASURES

Every 3 months for 1 year, we measured the volume of extraocular muscle and fat, proptosis, range of extraocular muscle motion, area of diplopia fields, and lid fissure width. Effective treatment for GO will modify one or more of these parameters.

RESULTS

No clinically or statistically significant difference between the treated and untreated orbit was observed in any of the main outcome measures at 6 months. At 12 months, muscle volume and proptosis improved slightly more in the orbit that was treated first.

CONCLUSIONS

In this group of patients, representative of those for whom radiotherapy is frequently recommended, we were unable to demonstrate any beneficial therapeutic effect. The slight improvement noted in both orbits at 12 months may be the result of natural remission or of radiotherapy, but the changes are of marginal clinical significance.

Autologous fat graft in irradiated orbit postenucleation for retinoblastoma

Autologous fat grafting has been extensively and successfully adopted in a number of pathologic conditions in regenerative surgery especially on irradiated fields in order to improve pain symptoms and tissue trophism promoting scar release. In the present study, we report our experience with autologous fat grafting for the treatment of postirradiation fibrosis and pain on three consecutive patients undergoing orbital enucleation for locally advanced retinoblastoma (RB) and subsequent radiotherapy. We selected three consecutive patients who underwent orbital enucleation for locally advanced RB and subsequent local radiotherapy showing severe reduction in orbital volume and eyelid length and retraction due to fibrosis, spontaneous local pain exacerbated after digital pressure with no possibility to place an ocular implant. They underwent autologous fat grafting in the orbital cavity and results were evaluated by clinical examination at 5 and 14 days, and 1, 3, 6 months, and 1 year after surgery. A significant release of scar retraction, reduction of fibrosis and orbital rim contraction together with an important improvement of pain symptoms was observed in all patients. The local changes observed enabled an ease placement of an ocular prosthetic implant (implant). No local or systemic complication occurred. Fat grafting is a promising treatment for patients showing radiotherapy related complication in the orbital area and it should be adopted by all oculoplastic surgeon in order to improve pain syndrome creating the ideal local conditions for the placement of an ocular prosthetic implant.

Effects on Periocular Tissues after Proton Beam Radiation Therapy for Intraocular Tumors

BACKGROUND

To present our experience on orbital and periorbital tissue changes after proton beam radiation therapy (PBRT) in patients with intraocular tumors, apart from treatment outcomes and disease control.

METHODS

Medical records of 6 patients with intraocular tumors who had been treated with PBRT and referred to oculoplasty clinics of two medical centers (Seoul National University Hospital and Seoul Metropolitan Government-Seoul National University Boramae Medical Center) from October 2007 to September 2014 were retrospectively reviewed. The types of adverse effects associated with PBRT, their management, and progression were analyzed. In anophthalmic patients who eventually underwent enucleation after PBRT due to disease progression, orbital volume (OV) was assessed from magnetic resonance (MR) images using the Pinnacle3 program.

RESULTS

Among the six patients with PBRT history, three had uveal melanoma, and three children had retinoblastoma. Two eyes were treated with PBRT only, while the other four eyes ultimately underwent enucleation. Two eyes with PBRT only suffered from radiation dermatitis and intractable epiphora due to canaliculitis or punctal obstruction. All four anophthalmic patients showed severe enophthalmic features with periorbital hollowness. OV analysis showed that the difference between both orbits was less than 0.1 cm before enucleation, but increased to more than 2 cm³ after enucleation.

CONCLUSION

PBRT for intraocular tumors can induce various orbital and periorbital tissue changes. More specifically, when enucleation is performed after PBRT due to disease progression, significant enophthalmos and OV decrease can develop and can cause poor facial cosmesis as treatment sequelae.

Orbital radiotherapy plus three-wall orbital decompression in a patient with rare ocular manifestations of thyroid eye disease: case report

BACKGROUND

Thyroid eye disease (TED) is a debilitating autoimmune orbital disease that is often a result of Graves' disease. Dysthyroid optic neuropathy (DON) is a rare but sight-threatening manifestation of TED with therapeutic challenges that can potentially lead to visual loss.

CASE PRESENTATION

A 74-year-old man experienced active TED with extremely severe redness and swelling of the conjunctiva, loss of visual acuity and exacerbation of disfiguring proptosis. Computed tomography revealed the involvement of extraocular muscles resulting in optic nerve compression. He was in poor general condition and was intolerant to steroids. To achieve the optimal operating conditions for orbital decompression surgery, the patient was initially treated with orbital radiotherapy. The patient responded well, with improvements in clinical activity score and visual acuity.

CONCLUSION

This case demonstrates a rare and severe case of DON with therapeutic challenges. To date, no cases has been reported of a patient with such severe and unusual ocular manifestations. Early awareness of the occurrence of optic nerve compression and prompt treatment are important to prevent irreversible outcomes. Orbital radiotherapy should be considered as a useful surgery-delaying alternative for DON, especially in patients who have contraindications to steroids.

Combination Therapy of Intravenous Steroids and Orbital Irradiation is More Effective Than Intravenous Steroids Alone in Patients with Graves' Orbitopathy

The aim of this study was to evaluate and compare the efficacy of intravenous (iv) glucocorticoids (GCs) with and without orbital radiotherapy (ORT) in a retrospective analysis of patients with active, moderate-to-severe Graves' orbitopathy (GO). Since diplopia has the strongest impact on quality of life, a careful work up of motility and binocular single vision (BSV) has been performed. The Essen-EUGOGO-Center database (n=3655) was screened for patients with untreated moderate-to-severe, active GO, onset ≤12 months. The inclusion criteria were met by 148 patients (n=76 ivGC, n=72 ivGC + ORT). We analyzed CAS (inactivation: ≤2), NOSPECS, lid-width, proptosis, motility, and field of BSV. To score the overall ophthalmic outcome, a severity-weighted-score (SOS) was compared with an established EUGOGO inflammation-weighted-score (IOS). Cumulative ivGCs dosages and duration of GO did not differ between the groups. Patients with combination therapy had a significantly more severe GO at baseline. Therefore, a subgroup with matched severity was additionally compared. In the IOS, both groups reached similar improvement rates (55.2 vs. 63.9%; p=0.31). However, in the SOS, the rates differed significantly (46.1 vs. 61.1%; p=0.03- unmatched and p=0.03 matched), despite similar rates of inactivation (65.8 vs. 63.8%). Impaired motility improved significantly more often after combination therapy (p=0.01 matched, p=0.004 unmatched). Treatment responders showed only partial improvement (proptosis: 2.5±0.5 mm; motility: 11.3±10.9°). In our retrospective analysis, combination therapy (ivGCs + ORT) was significantly more effective in reduction of severity and should therefore always be considered in moderate-to-severe GO stages, especially in the presence of motility disorders. However, the limited improvement in clinical parameters, despite the promising effect on inactivation of inflammation, has to be outlined to the patients.

The Effect of Systemic Steroids and Orbital Radiation for Active Graves Orbitopathy on Postdecompression Extraocular Muscle Volume

PURPOSE

To evaluate the effect of orbital radiation prior to surgery on the clinical course and extraocular muscle (EOM) radiologic volume changes after decompression in Graves orbitopathy (GO).

DESIGN

Retrospective, interventional case series.

METHODS

The medical records of patients treated with orbital decompression for GO and who underwent postoperative orbital computed tomography were reviewed. Only patients who underwent rehabilitative decompression in the inactive phase and who received systemic corticosteroids alone (ST group) or combined orbital radiation and systemic corticosteroids (SRT group) in the active inflammatory phase of the disease were selected. The main outcome measure was the comparison of preoperative and postoperative EOM volumes. Secondary outcome measures were changes in proptosis and diplopia after decompression.

RESULTS

Thirty-seven of 114 patients were selected for this study. There were no differences between the ST group (n = 22, 42 eyes) and SRT group (n = 15, 30 eyes) in terms of demographics or predecompression characteristics. After decompression surgery, the total EOM volume significantly increased by 15% in the ST group, but radiated EOMs in the SRT group did not expand, resulting in decreased induction of postoperative diplopia. The percentages of patients showing increased diplopia after decompression differed significantly between the groups (ST group, 40.9% vs SRT group, 13.3%, P = .04). However, there was no difference in exophthalmos reduction after decompression between the 2 groups.

CONCLUSIONS

Orbital radiation prior to orbital decompression can reduce both the postoperative increase in EOM volume and deterioration in diplopia.

Retinoblastoma with Cerebrospinal Fluid Metastasis Treated with Orbital and Craniospinal Irradiation Using IMRT

A 4-year-old male child presented with history of leucocoria, photophobia, and progressive visual deterioration in the left eye. Clinical examination and computed tomography revealed a unilateral retinoblastoma involving the left globe. He underwent enucleation of the left eye and was referred for adjuvant radiotherapy in view of optic nerve infiltration up to the line of resection. However, he did not report for treatment and presented six months later with a recurrent mass in the left orbit with intracranial extension. Cerebrospinal fluid (CSF) cytology was positive for malignant retinoblastoma cells. He received multiagent chemotherapy with vincristine, carboplatin, and etoposide along with intrathecal methotrexate. Although the recurrent orbital mass reduced significantly with chemotherapy, malignant cells persisted in the CSF. He was subsequently treated using intensity modulated radiation therapy (IMRT) to treat the left orbital mass along with craniospinal axis irradiation. Computed tomography done at three and nine months after completion of radiotherapy showed complete disappearance of orbital tumor. CSF cytology also showed no evidence of malignant cells.

Development of a Novel Thyroid Function Fluctuated Animal Model for Thyroid-Associated Ophthalmopathy

Background

The establishment of a suitable and stable animal model is critical for research on thyroid-associated ophthalmopathy (TAO). In clinical practice, we found that patients treated with I-131 often exhibit TAO; therefore, we aimed to establish a novel thyroid function fluctuated animal model of TAO by simulating the clinical treatment process.

Methods

We treated SD rats with I-131 to damage the thyroid and then used sodium levothyroxine (L-T4) to supplement the thyroid hormone (TH) levels every seven days, leading to a fluctuating level of thyroid hormones that simulated the status of clinical TAO patients. Rats administered normal saline were considered as a control. The weight, intraocular pressure, and serum T3, T4, TSH and TRAb levels of the rats were measured, and the pathological changes were analyzed by H&E staining and transmission electron microscopy (TEM).

Results

The experimental rats (TAO group) exhibited significantly reduced weight and elevated intraocular pressure compared with the control rats. Meanwhile, the serum levels of T3 and T4 were up-regulated in the TAO group, but the TSH level decreased during the 10-week study. Moreover, increased numbers of blood vessels and inflammatory cell infiltrations were observed in the orbital tissues of the TAO rats, while no abnormal changes occurred in the control rats. The orbital myofibrils in the TAO rats appeared fractured and dissolved, with twisted structures. Mitochondrial swelling and vacuoles within the endoplasmic reticulum, swelling nerve fibers, shedding nerve myelin, and macrophages were found in the TAO group.

Conclusion

Rats treated with I-131 and sodium levothyroxine exhibited characteristics similar to those of TAO patients in the clinic, providing an effective and simple method for the establishment of a stable animal model for research on the pathogenesis and treatment of TAO.

Dose reduction in orthodontic lateral cephalography: dosimetric evaluation of a novel cephalographic thyroid protector (CTP) and anatomical cranial collimation (ACC)

OBJECTIVES

To test the dose-reducing capabilities of a novel thyroid protection device and a recently introduced cranial collimator to be used in orthodontic lateral cephalography.

METHODS

Cephalographic thyroid protector (CTP) was designed to shield the thyroid while leaving the cervical vertebrae depicted. Using a RANDO(®) head phantom (The Phantom Laboratory, Salem, NY) equipped with dosemeters and a Proline XC (Planmeca, Helsinki, Finland) cephalograph, lateral cephalograms were taken, and the effective dose (ED) was calculated for four protocols: (1) without shielding; (2) with CTP; (3) with CTP and anatomical cranial collimator (ACC); and (4) with a thyroid collar (TC).

RESULTS

The ED for the respective protocols was (1) 8.51; (2) 5.39; (3) 3.50; and (4) 4.97 µSv. The organ dose for the thyroid was reduced from 30.17 to 4.50 µSv in Protocols 2 and 3 and to 3.33 µSv in Protocol 4.

CONCLUSIONS

The use of just the CTP (Protocol 2) resulted in a 36.8% reduction of the ED of a lateral cephalogram. This was comparable to the classical TC (Protocol 4). A 58.8% reduction of the ED was obtained when combining CTP and ACC (Protocol 3). The dose to the radiosensitive thyroid gland was reduced by 85% in Protocols 2 and 3 and by 89% in Protocol 4.

Acute dysthyroid optic neuropathy exacerbated by orbital radiotherapy

A 76-year-old lady presenting with acute dysthyroid optic neuropathy (DON) was stabilised with systemic intravenous methylprednisolone (IVMP). Two separate attempts at a treatment course of orbital radiotherapy (OR) were commenced and subsequently abandoned as there was an acute worsening of her DON during OR, despite cover with oral glucocorticoids and subsequently IVMP. The patient underwent urgent orbital decompression which normalised her vision and optic neuropathy. Our case likely represents worsening of DON due to soft tissue swelling secondary to OR despite cover with IVMP in a patient previously responsive to IVMP alone. Some authors advocate the use of OR in active DON as either a surgery delaying or surgery sparing alternative. This case report illustrates the rare risk of transiently worsening DON with OR. We highlight the need for close monitoring of optic nerve function if OR is utilised in this patient group.

Treatment of mild, moderate-to-severe and very severe Graves' orbitopathy

Treatment of Graves' orbitopathy (GO) is better performed through a multidisciplinary approach. Euthyroidism should be promptly restored. Antithyroid drug and thyroidectomy are not disease-modifying treatments, whereas radioiodine may be associated with worsening of GO. This risk is eliminated by glucocorticoid prophylaxis. Treatments for GO differ depending on its severity and activity. Mild forms should be treated with local measures. In addition a course of selenium may be beneficial. Glucocorticoids (oral or intravenous) represent the main treatment of moderate-to-severe GO, the intravenous route being more effective. Weekly pulses of methylprednisolone are used and the cumulative dose should not exceed 8 g. Severe adverse events have been reported, particularly with higher doses. Orbital radiotherapy can be used either alone or associated with glucocorticoids. In very severe sight-threatening GO high dose intravenous glucocorticoid should be the initial treatment, orbital decompression being considered in nonresponding patients. Rehabilitative surgery should be deferred until GO becomes inactive.

Immunotherapy in miscellaneous medical disorders Graves ophthalmopathy, asthma, and regional painful syndrome

In Graves ophthalmopathy, immunotherapy is offering an opportunity of reducing bad outcomes that lead to disfigurement and impairment of vision. These therapies are not perfect; however, we now have a chance to achieve better outcomes. In asthma, immune therapy using passive immunity targeting key proinflammatory cytokine/chemokines and medications of their effects has opened an avenue of research into a safe and durable therapy. Omalizumab appears to be safe and effective in clinical use. In regional pain syndrome, immune mechanisms may be involved in sustaining long-standing pain, and IVIG may moderate pain sensitivity by reducing immune activation.

Dosimetric study of current treatment options for radiotherapy in retinoblastoma

PURPOSE

To determine the best treatment technique for patients with retinoblastoma requiring radiotherapy to the whole eye.

METHODS AND MATERIALS

Treatment plans for 3 patients with retinoblastoma were developed using 10 radiotherapy techniques including electron beams, photon beam wedge pair (WP), photon beam three-dimensional conformal radiotherapy (3D-CRT), fixed gantry intensity-modulated radiotherapy (IMRT), photon volumetric arc therapy (VMAT), fractionated stereotactic radiotherapy, and helical tomotherapy (HT). Dose-volume analyses were carried out for each technique.

RESULTS

All techniques provided similar target coverage; conformity was highest for VMAT, nine-field (9F) IMRT, and HT (conformity index [CI] = 1.3) and lowest for the WP and two electron techniques (CI = 1.8). The electron techniques had the highest planning target volume dose gradient (131% of maximum dose received [D(max)]), and the CRT techniques had the lowest (103% D(max)) gradient. The volume receiving at least 20 Gy (V(20Gy)) for the ipsilateral bony orbit was lowest for the VMAT and HT techniques (56%) and highest for the CRT techniques (90%). Generally, the electron beam techniques were superior in terms of brain sparing and delivered approximately one-third of the integral dose of the photon techniques.

CONCLUSIONS

Inverse planned image-guided radiotherapy delivered using HT or VMAT gives better conformity index, improved orbital bone and brain sparing, and a lower integral dose than other techniques.

Severe thyroid-associated orbitopathy in Hashimoto's thyroiditis. Report of 2 cases

Thyroid-associated orbitopathy (TAO) is characterized by immune-mediated inflammation of the extraocular muscles surrounding orbital connective tissue and adipose tissue. Severe orbitopathy related to autoimmune thyroid disease often occurs in patients with Grave's disease, but it is rare in patients with Hashimoto's thyroiditis. The pathogenesis of TAO is unclear. Several studies have noted a strong correlation between the levels of antibodies to thyrotropin receptor antibody (TRAb) and TAO in Graves' disease. Mild upper eyelid retraction has been reported to be common in Hashimoto's thyroiditis patients, however severe orbitopathy is rare. We report two cases of severe TAO in patients with Hashimoto's thyroiditis who required systemic glucocorticoid therapy and orbital irradiation to treat the TAO. The activity of the TAO was high in both patients, because their clinical activity scores (CAS) for the orbitopathy were high, and magnetic resonance imaging (MRI) showed enlargement of the extraocular muscles and an increase in T2 signal intensity and prolonged T2 relaxation time which indicate an active stage of inflammation. We tested the presence of TRAb by three different assays and were negative in both patients. Since the eye muscle damage cannot be due to TSH receptor antibodies, other pathogenetic mechanisms may be responsible for the orbitopathy in patients with Hashimoto's thyroiditis.

[Effectiveness of infrared exposure to periorbital areas in partial optic nerve atrophy of varying degrees]

The paper gives the comparative results of infrared exposure, drug and multimodality treatment in partial optic nerve atrophy of varying degrees, as evidenced by Doppler, electrophysiological, and morphometric studies.

Infrared laser therapy after surgically assisted rapid palatal expansion to diminish pain and accelerate bone healing

The aim of this study was to illustrate how gallium arsenite aluminum diode laser (824 nm) irradiation can reduce postsurgical edema and discomfort and accelerate sutural osseous regeneration after surgically assisted rapid palatal expansion (SARPE). An adult patient with an 8-mm transverse maxillary discrepancy was treated with SARPE. Infrared laser therapy was started on the 7th postoperative day, with a total of eight sessions at intervals of 48 hours. The laser probe spot had a size of 0.2827 cm2 and was positioned in contact with the following (bilateral) points: infraorbital foramen, nasal alar, nasopalatine foramen, median palatal suture at the height of the molars, and transverse palatine suture distal to the second molars. The laser was run in continuous mode with a power of 100 mW and a fluency of 1.5 J/cm2 for 20 seconds at each point. Subsequently, an absence of edema and pain was observed. Further, fast bone regeneration in the median palatal suture could be demonstrated by occlusal radiographs. These findings suggest that laser therapy can accelerate bone regeneration of the median palatal suture in patients who have undergone SARPE.

[Effect of infrared low-intensity laser therapy on orbital blood circulation in children with progressive short sightedness]

This work was designed to study effect of low-intensity infrared laser radiation (LIIRR) on orbital circulation in children with progressive progressive short-handedness. Parameters of the blood flow in the orbital artery, central retinal artery, and posterior ciliary artery were evaluated in a total of 88 patients at the age from 6 to 14 years. The study group (group 1) comprised 66 children with moderately severe progressive myopia (112 eyes), the control one (group 2) included 22 patients without visual disturbances (44 eyes). Patients of group 1 received physiotherapy for the treatment of significantly deteriorated hemodynamics in the orbital region. Indirect action of LIIRR on the orbital region promoted stabilization of short-handedness in 78.8% of the treated patients. It is concluded that the method described in this paper is clinically efficient and may be recommended for the prevention of progressive myopia in children.

Treatment modalities for Graves' ophthalmopathy: systematic review and metaanalysis

BACKGROUND

Graves' ophthalmopathy (GO) is a common cause of morbidity in patients with Graves' disease. Optimal treatment of GO remains unclear, and an evidence-based approach may improve patients' outcome.

METHODS

A systematic review and metaanalysis of randomized, controlled trials comparing treatment modalities for GO vs. placebo, no intervention, or other treatments. Primary outcome was the clinical activity score (CAS).

RESULTS

Thirty-three trials evaluating 1367 patients fulfilled inclusion criteria. In patients with moderate to severe GO, iv pulse corticosteroids were significantly better than oral corticosteroids in reducing CAS [standardized mean difference -0.64, 95% confidence interval (CI) -1.11 to -0.17, chi(2) 7.91, I(2) 62%, random effect], with lower rate of adverse events. Somatostatin analogs showed a minor but statistically significant advantage over placebo (mean difference -0.63, 95% CI -0.98 to -0.28). There was no advantage of orbital radiotherapy over sham radiation in CAS, but radiotherapy was superior for response rates of diplopia (odds ratio 4.88, 95% CI 1.93-12.34, two trials). Treatment with combination of orbital radiotherapy and corticosteroids was significantly better than with either treatment alone (standardized mean difference -1.05, 95% CI -1.62 to -0.48).

CONCLUSIONS

Current evidence demonstrates the efficacy of iv corticosteroids in decreasing CAS in patients with moderate to severe GO. Intravenous pulse corticosteroids therapy has a small but statistically significant advantage oral therapy and causes significantly fewer adverse events. Somatostatin analogs have marginal clinical efficacy. The efficacy of orbital radiotherapy as single therapy remains unclear, whereas the combination of radiotherapy with corticosteroids has better efficacy than either radiotherapy or oral corticosteroids alone.

Effect of combined intravenous glucocorticoids and orbital radiotherapy in restoring driving competency in patients with Graves' orbitopathy

Intravenous glucocorticoids and orbital radiotherapy are effective treatments for moderate-to-severe and active Graves' orbitopathy. We examined the ophthalmological outcome in daily life activities, such as driving competency. In a retrospective case series, 23 patients with moderate-to-severe and active Graves' disease (14 women and 7 men) were consecutively treated with combined orbital radiotherapy (13 Gy) and intravenous methylprednisolone (500 mg weekly for 6 consecutive weeks and 250 mg weekly for consecutive 6 weeks). The pretreatment Clinical Activity Score of 5.2 points (SD+/-0.9) decreased significantly to 2.7 points (SD+/-1.1) in the 12-month follow-up. Inflammatory eye signs, for example, pain and pressure sensation, caruncle inflammation, eyelid swelling, and exophthalmos decreased significantly. However, there was no significant improvement of eye motility. Despite anti-inflammatory treatment, 13 patients (61.9%) were not fit to drive a car under binocular conditions and additional stabismologic therapy including strabismus surgery was required. The combined therapy of intravenous glucocorticoids and orbital radiotherapy reduced inflammatory ophthalmological signs. In most cases strabismologic intervention including eye muscle surgery was necessary to restore driving competency.

The influence of previous orbital irradiation on the outcome of rehabilitative decompression surgery in graves orbitopathy

PURPOSE

To investigate whether orbital irradiation influences the outcome of decompression surgery in Graves orbitopathy.

DESIGN

Retrospective, comparative case series.

METHODS

The medical records of all the patients with Graves orbitopathy treated with a three-wall orbital decompression through a coronal approach at our institution between January 1, 1990 and December 31, 2000 were reviewed. Only patients who underwent bilateral surgery for aesthetic rehabilitation, without preoperative diplopia, and who, in the active phase of the disease, had received orbital radiotherapy alone (20 Grays (Gy) in 10 daily fractions of two Gy over a period of two weeks; group R), systemic glucocorticoids alone (daily administration for more than three months independently from the dosage; group G), or both radiotherapy and glucocorticoids (group RG) were selected. Groups were compared for demographics, smoking habits, preoperative characteristics, and surgical outcome (mean reduction of exophthalmos, reduction of lid retraction, persistence of periorbital swelling requiring cosmetic eyelid surgery, onset of diplopia within 20 degrees of the central position of gaze, and variations in the peripheral field of diplopia).

RESULTS

Sixty-one of 376 patients were selected for this study. There were no differences between group R (n=29), group G (n=15), and group RG (n=17) with respect to demographics or predecompression characteristics, whereas the number of smokers was significantly greater in group RG (P=.019). We could not find differences in surgical outcome by comparing the three groups.

CONCLUSIONS

The total radiation dose, fraction size, and irradiated volume commonly used to treat active Graves orbitopathy do not adversely interfere with the outcome of rehabilitative decompression surgery.

An in vitro model of radiation-induced craniofacial bone growth inhibition

Radiation-induced craniofacial bone growth inhibition is a consequence of therapeutic radiation in the survivors of pediatric head and neck cancer. Previously, the infant rabbit orbitozygomatic complex (OZC) was established as a reliable animal model. The purpose of this study was to develop a cell culture model from the rabbit OZC to study the effects of radiation in the craniofacial skeleton. Infant (7-week-old) New Zealand white rabbits were used in this study. Periostea from both OZC were harvested in sterile conditions, introduced into cell culture by way of sequential digestion, and subcultured at confluence. Cultures were analyzed for cellular proliferation (methylthiazoletetrazolium assay), alkaline phosphatase activity, collagen type I expression, and mineralization. Electron microscopy was performed to reveal the in vitro ultrastructure. Subsequently, rabbits were irradiated with sham or 15 Gy radiation, and cell cultures were developed and analyzed for cell numbers. Cell cultures, grown from OZC periostea, expressed osteoblast-like phenotype, with high alkaline phosphatase activity, collagen type 1 expression, and mineralization in an osteogenic environment. Electron microscopy confirmed the characteristic ultrastructural features of osteogenesis in vitro. Finally, significantly (P < 0.01) fewer cells were obtained from animals treated with 15 Gy radiation compared with those from control animals.A primary cell culture with osteoblast-like cellular phenotype was developed from infant rabbit OZC periosteum. This cell culture system responded to in vivo administered radiation by a significant decrease in cell numbers. This in vitro model will be subsequently used to study the cellular mechanisms of radiation and radioprotection in craniofacial osteoblast-like cells.

[Malignant exophtalmos in hyperthyroidism with a hypothyroid crisis]

CASE REPORT

We present the case of a 56-year-old male with a malignant exophthalmos in the context of Graves' disease. He suffered a significant worsening coincident with a hypothyroid crisis, and various therapeutic approaches were required for reduction of the proptosis.

DISCUSSION

When managing this condition, both the severity of the exophthalmos and the activity of the thyroid must be considered when choosing which of the different therapeutic approaches should be employed.

Use of osseointegrated implants in the restoration of head and neck defects

Osseointegrated implants can be applied to facilitate retention, stability, and support for facial and intraoral prostheses used to restore head and neck defects. At the University of California, Los Angeles, Maxillofacial Prosthetics Clinic, retrospective studies have indicated that in nonirradiated maxillectomy patients, implant survival rates are 82.6 percent. In mandibles reconstructed with fibula free flaps, survival rates are 94.6 percent. Similarly, high implant survival rates have been observed for most sites used to support facial prostheses. Cumulative six-year survival rates for auricular sites exceed 95 percent and for floor of nose sites, success rates exceed 87 percent. However, survival rates are low (53 percent) for implants placed in the frontal bone for retention of orbital prostheses and even lower for irradiated bone sites ranging from 63 percent in the maxilla to 27 percent in the orbit.

Retrieved Implants from Irradiated Sites in Humans: A Histologic/Histomorphometric Investigation of Oral and Craniofacial Implants

PURPOSE

The aim of this report was to quantitatively and qualitatively evaluate the tissue response to bone-anchored implants retrieved from irradiated sites in patients.

MATERIALS AND METHODS

The material consists of 23 consecutively received Brånemark implants (Nobel Biocare AB, Göteborg, Sweden) placed in pre- or postoperatively irradiated sites. Twenty-two of the 23 implants were suitable for histologic evaluation of undecalcified sections in the light microscope.

RESULTS

The oral implants with shorter time in situ demonstrated sparse bone to implant contact with mainly dense connective tissue in the interface. However, for implants with longer time in situ, high amounts of bone-implant contact and bone fill of threads were noted. The mean values of bone-implant contact and bone area within the thread were calculated to 40% (16-94) and 70% (13-96), respectively. The craniofacial implants, with the exception of two implants lined with a capsular formation, demonstrated mature and newly formed bone at the bone-implant interface. The mean value for bone-metal contact was calculated to 45 and 53% for two specimens. The mean value for bone area within the thread ranged from 65 to 88% for three specimens. CONCLUSION; The possibility to achieve bone anchorage of implants in irradiated tissue was supported by the findings in this study. However, due to limited material, conclusions with regard to radiation dose and bone tissue response to implants cannot be stated.

Idiopathic Sclerosing Orbital Inflammation

OBJECTIVE

To perform a multicenter review of the clinical features and treatment of 31 patients with idiopathic sclerosing orbital inflammation.

METHODS

We included all patients with histologically confirmed idiopathic sclerosing orbital inflammation from 5 regional orbital centers. We reviewed the case notes to determine the clinical presentation, diagnostic features, and response to treatment. The main outcome measures were duration and nature of symptoms, anatomical location of disease, histopathological findings, treatment modalities, treatment efficacy and adverse effects, and final clinical status.

RESULTS

We included 13 male and 18 female patients ranging in age from 7 to 83 years. The average duration of symptoms at presentation was 13.4 months. There was a predilection for the lateral and superior quadrants. Thirteen patients had apical disease, and 4 had extraorbital involvement. Histopathological findings invariably showed sclerosis associated with a sparse mixed cellular infiltrate. Twenty-seven patients were treated with oral prednisolone, response to which was good in 9 patients, partial in 11, and poor in 7. Six patients were treated with a second-line immunosuppressive agent, and 6 received radiotherapy. The response to radiotherapy was generally poor.

CONCLUSIONS

Idiopathic sclerosing orbital inflammation is a rare condition that can be difficult to diagnose and manage. Early intervention with immunosuppression in the form of corticosteroids combined with second-line agents can result in control and even regression of the disease.

Recent developments in the medical treatment of thyroid eye disease

No real new treatment has been developed in the last decade for thyroid eye disease (TED). Glucocorticoids (GC), orbital radiotherapy (OR) or a combination of both, are most frequently used in the treatment of TED for the iv immunosuppressive effects. However, we now have novel information regarding the when and how corticosteroids should be used. In general, the iv route of GC administration is preferable to the oral use. iv GC should be used at much lower doses than previously (4.5 to 6 g cumulative dose), possibly with a small dose of oral prednisone (or equivalent) in the interpulse period and for a few weeks after completion of iv treatment. Careful assessment of patients before treatment for identification of possible risk factors of liver toxicity is mandatory. Finally, monitoring of patients, particularly for liver function, is warranted during and after treatment. Although OR's effectiveness was disputed by a study few years ago, more recent studies have reconfirmed its beneficial role in TED and shown that it still has a positive role to play in patients with active TED. Finally, although Somatostatin-analogs (SM-as) gave the impression some years ago that might represent an effective weapon for TED management and initial, mostly uncontrolled and non-randomized trials with small number of patients supported this notion, newer randomized, double-blind studies with larger number of patients have not confirmed the first optimistic results. The question after that is if SM-as should be considered as a rubber bullet in the treatment of TED and we have to forget about them. The answer should be "no yet," especially in the light that the role of SM-as may be revitalized by the use of analogs with higher affinity for all somatostatin receptors subtypes. Such analogs are now available and under investigation in different diseases with very promising results.

Radiation-induced craniofacial bone growth inhibition: efficacy of cytoprotection following a fractionated dose regimen

BACKGROUND

Severe craniofacial growth disturbances are noted in 66 to 100 percent of children with head and neck cancers who received radiotherapy during their growing years. The authors have previously demonstrated the prevention of radiation-induced craniofacial bone growth inhibition following single-dose orthovoltage radiation to the orbitozygomatic complex in an infant rabbit model through the administration of the cytoprotective agent amifostine (WR-2721) before radiation treatment. The purpose of this study was to investigate the efficacy of cytoprotection using a fractionated dose regimen that better approximates the clinical application of radiation therapy.

METHODS

Thirty 7-week-old male New Zealand rabbits were randomized into three groups (n = 10), each receiving six fractions of orthovoltage radiation to the right orbitozygomatic complex: group C, sham irradiation control; group F35, total dose of 35 Gy; and group F35A, total dose of 35 Gy with administration of amifostine 200 mg/kg intravenously 20 minutes before each fraction. Bone growth was evaluated up to skeletal maturity (age 21 weeks) with serial radiographs and computed tomography scans for cephalometric analysis, bone volume, and bone density measurements.

RESULTS

Fractionated radiation resulted in significant (p < 0.05) bone growth inhibition compared with sham radiation in 16 of 21 cephalometric parameters measured and significantly (p < 0.05) reduced bone volume of the rabbit orbitozygomatic complex. Pretreatment with amifostine before each radiation fraction prevented growth deformities in four cephalometric parameters and significantly (p < 0.05) attenuated these effects in another seven parameters compared with radiated animals. Bone volumes were also significantly (p < 0.05) improved in F35A animals compared with F35 animals.

CONCLUSIONS

This study establishes that fractionation of orthovoltage radiation does not prevent the development of growth disturbances of the rabbit craniofacial skeleton and also demonstrates that preirradiation administration of amifostine is highly effective in the prevention and attenuation of radiation-induced craniofacial bone growth inhibition.

Corneal Topography in Thyroid Orbitopathy After Orbital Irradiation

PURPOSE

The orbital tonus changes in thyroid orbitopathy, so it may be expected that corneal topographic results also change. Orbital irradiation may reduce the orbital tonus, and thus, it may affect the topographic changes. Corneal topographic results were examined before and after orbital irradiation in patients with thyroid orbitopathy to determine whether there was a difference.

METHODS

Twenty eyes of 10 patients with thyroid orbitopathy were included in this study. Corneal topography was performed with Topographic Modeling System 2 (Tomey). The refractive power of the corneal curvature was measured at the center of the corneal apex and in each of the eight quadrants, 1.5 mm and 3 mm from the corneal apex, on the corneal topographer. A total dose of 20 Gy was given in 10 fractions over 2 weeks to the orbital structures sparing the lens, and corneal topography was performed 6 weeks and 8 months later. The measures of the refractive power of the cornea were taken again. Repeated-measures analysis of variance was used to evaluate the differences between the measures.

RESULTS

There were no statistically significant differences in refractive power of the cornea in the topographic maps obtained before the radiotherapy and the two follow-up examinations after the radiotherapy.

CONCLUSIONS

Thyroid orbitopathy is an orbital disease and may affect corneal topographic results. Orbital irradiation reduces or eliminates pathogenic orbital lymphocyte infiltration, thereby reducing orbital and extraocular muscle edema in patients with thyroid orbitopathy. In the current study group, corneal topographic changes were observed minimally as a result of the orbital irradiation, but they were not statistically significant.

Orbital radiotherapy for thyroid-related orbitopathy

PURPOSE OF REVIEW

Orbital radiotherapy has been one of the primary treatment modalities for moderate to severe thyroid-related orbitopathy. In this review the authors discuss the role of orbital radiotherapy in this disease with particular emphasis on questions raised by recent studies.

RECENT FINDINGS

Despite its widespread use, until recently there have been few well-designed, randomized clinical trials on the role of orbital radiotherapy for thyroid-related orbitopathy. Although most the literature points to a favorable effect of orbital radiotherapy, recent studies have provided us with conflicting results.

SUMMARY

Orbital radiotherapy remains a safe and a widely used treatment option for severe and progressive thyroid-related orbitopathy. More randomized clinical trials are needed, especially to examine the role of orbital radiotherapy for severe thyroid-related orbitopathy characterized by severe congestion and/or compressive optic neuropathy with and without the use of corticosteroids. There is a wide consensus among clinicians that this subgroup of patients is the most frequent one to which orbital radiotherapy is offered.

Radiotherapie der endokrinen Orbitopathie

Graves' ophthalmopathy (GO) is the most frequent extrathyroidal manifestation of Graves' disease, an autoimmune disorder of the thyroid, whereas the precise pathogenesis still remains unclear. In Hashimoto's thyroiditis the occurrence of proptosis is an extremely rare event. The therapy for middle and severe courses of GO shows in partly disappointing results, although several therapy modalities are possible (glucocorticoid therapy, radiotherapy, antithyroid drug treatment, surgery). All these therapies lead in only 40 - 70 % to an improvement of the pathogenic symptoms. An intensive interdisciplinary cooperation is necessary to satisfy the requirements for the treatment of Graves' ophthalmopathy. As a consequence of the very different results of the few of clinical studies that were accomplished with reference to this topic, treatment by radiotherapy in the management of the disease is presently controversially discussed. In the German-speaking countries the radiotherapy is, however, firmly established as a therapy option in the treatment of the moderate disease classes (class 2-5 according to NO SPECS), especially if diplopia is present. This article describes the sequences, dosages and fractionation schemes as well as the risks and side effects of the radiotherapy. Altogether, radiotherapy is assessed as an effective and sure method. The administration of glucocorticoids can take place before the beginning of or during the radiotherapy. For the success of treatment the correct selection of patients who may possibly profit from a radiotherapy is absolutely essential. By realising that GO proceeds normally over a period of 2-5 years, which is followed by a period of fibrotic alteration, the application of the radiotherapy in the early, active phase is indispensable. A precise explanation for the effects of radiotherapy in treatment of the GO does not exist at present. The determination of the most effective irradiation doses was made from retrospectively evaluated collectives. Recently the results of a national survey of all German RT departments were published, initiated by the working group of the DEGRO (German Society of Radiooncology). In the most of the German radiooncology departments irradiation with 8 to 10 x 1.8-2.0 Gy 5 x weekly to 16 or 20 Gy is standard. Two recently published prospective German studies pointed out the equivalence of the effectiveness of a short therapy in low dose ranges up to 2.4 Gy as well as of a low proportioned irradiation during a longer period in relation to a standard therapy with 20 Gy. That is why at the moment it is not possible to give a definite recommendation with reference to dosages or the fractionation schemes. In 2003 the first European group (European Group on Graves ' Orbitopathy Experience -- EUGOGO) was founded for pursuing investigations of GO in multi-centric studies, mainly to improve therapy results.

Orbital irradiation for Graves' ophthalmopathy: Is it safe? A long-term follow-up study

PURPOSE

We evaluated the frequency of long-term complications of orbital irradiation (radiation-induced tumors, cataract, and retinopathy) in comparison with glucocorticoids.

DESIGN

We conducted a follow-up study in a cohort of 245 Graves' ophthalmopathy patients who had been treated with retrobulbar irradiation (20 Gy in 2 weeks) and/or oral glucocorticoids between 1982 and 1993 in our institution. Irradiated patients were compared with nonirradiated patients.

METHODS

Data on mortality and cause of death were obtained. Living patients were invited to participate in a follow-up study. Possible retinopathy was assessed in a masked fashion and defined as the presence of > or =1 hemorrhages and/or microaneurysms on red-free retina photographs. If >5 lesions were present, patients were categorized as suffering from definite retinopathy. Cataract was assessed using the Lens Opacity Classification System II score.

MAIN OUTCOME MEASURES

Mortality, prevalence of retinopathy, prevalence of cataract, and type of cataract.

RESULTS

Thirty-seven of the 245 patients had died, none of them from an intracranial tumor. Mortality was similar in the irradiated (27/159 [17%]) and nonirradiated patients (10/86 [12%]; P = 0.264). One hundred fifty-seven of the 208 living patients (75%) consented to participate in a follow-up ophthalmologic investigation; the mean follow-up time (+/- standard deviation) was 11+/-3 years. Possible retinopathy was present in 15% of patients, 22 of the irradiated and 1 of the nonirradiated patients (P = 0.002). In 5 patients (all had been irradiated), definite retinopathy (i.e., >5 retinal lesions) was present. Of these, 3 had diabetes mellitus, and 1 had hypertension. Diabetes was associated with both possible (P = 0.029) and definite (P = 0.005) retinopathy, with a relative risk of 21 (95% confidence interval, 3-179). The prevalence and severity of cataract were similar in the radiotherapy group (29%) and the glucocorticoid group (34%); it should be noted that 88 of 104 of the irradiated patients were also treated with oral glucocorticoids.

CONCLUSION

The data suggest that orbital irradiation for Graves' ophthalmopathy is a safe treatment modality, except possibly for diabetic patients.

Intensity-modulated Radiation Therapy for Children with Intraocular Retinoblastoma:Potential Sparing of the Bony Orbit

AIMS

We have evaluated the potential for intensity-modulated radiation therapy (IMRT) to reduce dose to surrounding normal tissues in children with retinoblastoma confined to the globe of the eye.

MATERIALS AND METHODS

Treatment planning computed tomography (CT) scans from five children were used for comparison of four radiotherapy techniques to treat the eye. IMRT, conformal, anterior-lateral photon and en face electron plans were generated using the Corvus (NOMOS) and PLUNC treatment planning systems. Doses to surrounding critical structures were compared after normalisation of target coverage.

RESULTS

The IMRT treatment technique allowed the greatest sparing of the surrounding bony orbit, with an average of 60% of the ipsilateral bony orbit treated above 20 Gy and 48% treated above 24 Gy when 45 Gy is prescribed to the globe. IMRT techniques reduced dose to the surrounding bony orbit by more than one-third compared with anterior-lateral photon and electron techniques, and by 23% compared with conformal techniques. The application of IMRT also reduced dose to other surrounding normal tissues, including the temporal lobe and contralateral orbit.

CONCLUSION

IMRT shows potential for protecting normal tissues in patients requiring external beam radiation therapy for retinoblastoma.

Retinal microvascular abnormalities in patients treated with external radiation for graves ophthalmopathy

BACKGROUND

A prospective study was conducted to determine if external ionizing radiation could favorably influence the orbital manifestations of Graves ophthalmopathy. Diabetes and untreated systemic hypertension were exclusion criteria. Radiation was directed to the orbits of 42 affected patients using 0.2 rad (20 Gy) delivered in 10 doses of 0.02 rad (2 Gy). Patients were periodically examined during a 3-year interval.

OBJECTIVE

To report retinal microvascular abnormalities observed in our study cohort.

METHODS

Fundus findings documented with ophthalmoscopy, stereoscopic color photography, and stereoscopic fluorescein angiography prior to radiation were compared with similarly documented findings approximately 3 years following radiation.

RESULTS

Prior to orbital radiation, retinal microvascular abnormalities were identified in 2 patients. The abnormalities were present bilaterally in one patient and unilaterally in the other. During the course of the study, microvascular abnormalities developed de novo in the unaffected retina of the latter patient while the retinopathy in the fellow eye progressed. Retinal microvascular abnormalities and their sequelae developed de novo in both eyes in 2 more patients. In addition to the radiation, other confounding factors known to be associated with microvascular retinopathy (uveitis, inadequately controlled systemic hypertension, and borderline blood glucose levels) were identified among the 3 patients whose eyes developed new retinal microvascular abnormalities.

CONCLUSIONS

Whether the retinal microvascular abnormalities observed in these patients were caused or aggravated by external beam irradiation cannot be precisely ascertained. However, the observed progression and de novo development of retinal microvascular abnormalities within 3 years of orbital radiation raise concern that 0.2 rad (20 Gy) delivered to the orbit in 10 doses of 0.02 rad (2 Gy) may aggravate existing retinal microvascular abnormalities or cause radiation retinopathy in some patients with Graves disease. These findings and the failure of external beam radiation with 0.2 rad (2000 cGy) to favorably affect Graves ophthalmopathy, as demonstrated in a previous study, have led us to discourage further treatment of Graves ophthalmopathy with radiation.

Effect of steroid pulse therapy with and without orbital radiotherapy on Graves' ophthalmopathy

PURPOSE

To report the effect of high-dose intravenous corticosteroid pulse therapy with and without orbital radiotherapy on Graves' ophthalmopathy.

DESIGN

Nonrandomized clinical trial.

METHODS

We selected 39 Japanese patients (age range, 22-64 years; mean, 48 years; 31 women, 8 men) who had active Graves' ophthalmopathy among 195 consecutive patients. In the first 20 patients, high-dose intravenous methylprednisolone pulse therapy (1 g per day for 3 successive days, repeated 3 times within 3 weeks) followed by 24-Gy orbital radiotherapy was performed. In the other 19 of the 39 patients, high-dose intravenous methylprednisolone pulse therapy without orbital radiotherapy was performed. Coronal computed tomography (CT) of the orbit and exophthalmometry were performed before the corticosteroid pulse therapy, and 1 and 6 months after the corticosteroid pulse therapy. The maximum coronal section area of the most hypertrophic rectus muscle in each eye was measured based on orbital CT imaging.

RESULTS

Clinical findings at study entry were not significantly different between the two groups. No significant difference was found in the maximum coronal section area of the most hypertrophic rectus muscle and the results of exophthalmometry measurements in both groups before the therapy. Extraocular muscle hypertrophy was significantly reduced 1 month and 6 months after the therapy (P < .01) in both groups. However, no beneficial therapeutic effect on proptosis was observed in either group at 1 month and 6 months after the therapy. No significant difference in the therapeutic effect on extraocular muscle hypertrophy and proptosis was found between the two groups.

CONCLUSIONS

Orbital irradiation after corticosteroid pulse therapy had no beneficial therapeutic effects on rectus muscle hypertrophy or proptosis of active Graves' ophthalmopathy during the 6-month follow-up period.

Orbital radiotherapy for Graves' ophthalmopathy: useful or useless? Safe or dangerous?

Treatment of Graves' ophthalmopathy does not always provide favorable results. After several decades of efforts, glucocorticoids, orbital radiotherapy (OR) and surgery (orbital decompression) remain the milestones in the management of this disease. OR produce favorable results in about 55-60% of patients. Its effectiveness is increased by the association with systemic glucocorticoids. Recent studies have cast some doubts on its real effectiveness and this is discussed by participants in this Forum. Selection of patients is particularly important to assess treatment outcome, because OR is unlikely to provide beneficial effects in patients with longstanding and inactive eye disease. OR is a safe procedure, with very limited side-effects. It should be used in patients older than 35 years of age. It is recommended that a large, multi-center, prospective, randomized and controlled study with well defined inclusion criteria be carried out to draw sound conclusions on the role of OR in the management of Graves' ophthalmopathy.

[Retrobulbar irradiation for Graves' ophthalmopathy -- long-term results]

BACKGROUND

Significance of retrobulbar irradiation in patients suffering form Graves' ophthalmopathy, though established since almost one century, is subject of scientific debate. The present study investigated the effect of retrobulbar irradiation using a standardized protocol focussing on long term results.

PATIENTS AND METHODS

Between 1981 and 1997, 104 patients treated by retrobulbar irradiation (10 to 20 Gray) due to Graves' disease. Twenty-nine of these underwent irradiation as sole treatment (mean follow-up 57 months), while in the remaining 75, it was combined with a systemic steroid treatment (mean follow-up 40 months). Patients were evaluated regarding proptosis, intraocular pressure, lid signs, motility as well as subjective assessment of double vision and retrobulbar pain.

RESULTS

While proptosis remained unchanged, lid signs, chemosis and intraocular pressure showed slight and statistically significant improvement. However, these findings were considered to be clinically insignificant. Retrobulbar pain was improved in 75 % of patients. 25 % of patients showed improved motility, 75 % remained stable, and in none of them was there a deterioration of ductions. Results proved stable even in long-term follow-up. 25 % per cent of patients underwent a surgical procedure one year after radiotherapy.

CONCLUSIONS

In our series, we could not demonstrate an additional benefit of systemic steroids when combined with retrobulbar irradiation. Up to sixteen years after treatment, no treatment-related adverse reaction was seen. We found a remarkable improvement in ocular motility. This holds even more true in comparison to the natural course of the condition. Retrobulbar irradiation seems to shorten the duration of the disease, thus allowing earlier performance of eventual rehabilitative surgery.

The aftermath of orbital radiotherapy for graves' ophthalmopathy

OBJECTIVE

To determine whether long-term improvement could be observed after orbital radiotherapy for Graves' disease; in addition, to evaluate ancillary treatments needed for those who have received radiotherapy, to search for late-emerging adverse consequences of radiotherapy, and to relate orbital changes to serum levels of thyroid-stimulating immunoglobulin (TSI).

DESIGN

Three-year follow-up of noncomparative interventional case series.

PARTICIPANTS

Forty-two patients.

INTERVENTION

All patients had received orbital radiotherapy within 6 months of study entry. Twelve months after study entry, patients were free to select any additional treatment for their ophthalmopathy.

MAIN OUTCOME MEASURES

Need for surgery, steroid therapy, volume of extraocular muscles and fat, proptosis, area of diplopia fields and range of extraocular muscle motion, volume changes after decompression and correlations of eye findings with serum TSI levels, retinal status.

RESULTS

Half of the patients elected to have a surgical procedure on their eyes or orbits. Among patients who were not decompressed, we found only slight improvement in some of the main outcome measures. TSI did not positively correlate with baseline status or with any observed change in major outcome measures. After orbital decompression, the volumes of both muscle and fat increase, but bony orbital volume increases more and proptosis diminishes. Retinal microvascular abnormalities consistent with radiation retinopathy developed de novo in five eyes of three patients within 3 years of radiation therapy.

CONCLUSIONS

In this 3-year uncontrolled follow-up phase, limited evidence for a clinically significant improvement was observed, which may be the result of treatment or of natural remission. In either case, the changes are of little clinical significance. Because it is neither effective nor innocuous, radiotherapy does not seem to be indicated for treatment of mild to moderate ophthalmopathy.

Orbital, thyroid, and breast superficial radiation shielding for patients undergoing diagnostic CT

Computed tomography (CT) now provides over 30% of all radiation received from medical imaging. Superficial radiosensitive organs, such as the thyroid, eyes, and breasts receive a greater proportion of this radiation because of increase scatter and the lack of overlying other tissues to partially absorb some of the dose. This article describes the use of bismuth radioprotective garments to shield these radiosensitive areas while preserving the overall quality of the diagnostic image.

Efficacy of radioprotection in the prevention of radiation-induced craniofacial bone growth inhibition

It has been reported that radiotherapy-induced craniofacial deformities can occur in 66 to 100 percent of survivors of childhood head and neck cancers. Recent interest in the effectiveness of radioprotectors in the protection of normal tissue against radiation injury led us to investigate a possible role of radioprotection in the prevention of radiation-induced craniofacial bone growth inhibition. Therefore, the objective of this study was to use the radioprotective agent amifostine (Ethyol, WR-2721) as a probe to determine the effectiveness of radioprotection in the prevention of radiation-induced craniofacial bone growth inhibition after single-dose orthovoltage radiation to the infant rabbit orbital-zygomatic complex. Seven-week-old male New Zealand white rabbits were randomized into three groups (n = 10 each): group 1, 0 Gy (sham radiation); group 2, 35-Gy single-dose orthovoltage radiation; and group 3, 35-Gy single-dose orthovoltage radiation and amifostine (300 mg/kg intravenously, given 20 minutes before radiation). Serial radiographs and computed tomographic scans were obtained for cephalometric analysis, bone volume, and bone density measurements until skeletal maturity at 21 weeks. Significant (p < 0.05) reductions in orbital-zygomatic complex linear bone growth, bone volume, and bone density were observed after 35-Gy radiation compared with nonirradiated controls. No significant differences were noted between groups in cephalometric analysis of the nontreated (nonirradiated) left orbital-zygomatic complex, indicating no crossover effect from the radiation beam. However, pretreatment with amifostine, 20 minutes before 35-Gy radiation, resulted in significant (p < 0.05) preservation of linear bone growth, bone volume, and bone mineral density in the rabbit orbital-zygomatic complex compared with controls. This study demonstrated for the first time the effectiveness of a radioprotector in the prevention of radiation-induced craniofacial bone growth inhibition, and it paves the way for investigation into the pathogenic mechanism and prevention of radiotherapy-induced craniofacial deformities.

Radiotherapy in thyroid eye disease: the effect on the field of binocular single vision

PURPOSE

Thyroid eye disease (TED) can be a functionally disabling condition if ocular muscle involvement causes diplopia. The extraocular muscle restriction creates a reduced or eccentric field of binocular single vision (BSV). Orbital radiotherapy is now widely used in the treatment of TED, and although it has been reported as improving ocular motility, there have been few quantitative studies of the effect of treatment on ocular motor function.

METHODS

Retrospective case note review of patients undergoing orbital radiotherapy for TED between 1992-1998 identified 79 case records. A total of 27 patients had diplopia in primary position or a significantly reduced binocular field before undergoing radiotherapy. The fields of BSV were analyzed pretreatment and at 3, 12, and 24 months after therapy to assess any improvement in function. We used the field of BSV as an outcome measure because it can be quantified and is a good indicator of functional ability.

RESULTS

None of the 12 patients with double vision in primary position pretreatment regained a central binocular field with radiotherapy alone. Of the 15 patients with a central but reduced binocular field, 8 (53%) remained unchanged with treatment. In 4 patients (26.6%), there was an improvement in the field, while in 3 (20%) the field deteriorated. In all, 12 patients (44%) went on to require strabismus surgery.

CONCLUSIONS

Orbital radiotherapy alone is ineffective in treating restrictive thyroid myopathy and improving binocular function.