Radiotherapy in the management of thyroid orbitopathy. Computed tomography and clinical outcomes

Unilateral proptosis in thyroid eye disease with subsequent contralateral involvement: retrospective follow-up study

Background

The purpose of this retrospective follow-up study is to evaluate the prevalence of patients with thyroid eye disease presenting with apparent unilateral proptosis and determine the occurrence of exophthalmos in contralateral non-proptotic eye over the time. Associated features with this event were evaluated.

Methods

A cohort of 655 consecutive patients affected by thyroid eye disease with a minimum follow-up of 10 years was reviewed. Exophthalmos was assessed by using both Hertel exophthalmometer and computed tomography (CT). The influence of age, gender, hormonal status and of different therapies such as corticosteroids, radiotherapy and surgical decompression on this disease progression was evaluated.

Results

A total of 89 patients (13.5%) (95% confidence interval [CI] 15%-10%) had clinical evidence of unilateral exophthalmos at the first visit. Among these, 13 patients (14%) (95% CI 22%-7%) developed subsequent contralateral exophthalmos. The increase of protrusion ranged from 2 to 7 mm (mean of 4.2). The time of onset varied from 6 months to 7 years (mean time: 29 months). Smoking status, young age and surgical decompression are significantly associated with development of contralateral proptosis (p< .05).

Conclusions

Asymmetric thyroid eye disease with the appearance of unilateral exophthalmos at the initial examination is a fairly frequent event, while subsequent contralateral proptosis occurs less commonly. However, physicians should be aware that young patients, particularly if smokers, undergoing orbital decompression in one eye may need further surgery on contralateral side over time.

Effect of radiation therapy on intraocular pressure in patients with Graves' orbitopathy

PURPOSE

To describe the effect of radiation therapy on intraocular pressure in patients who have had orbital radiation for Graves' orbitopathy, and to provide a descriptive analysis of these patients.

DESIGN

Retrospective case series.

PARTICIPANTS

24 consecutive patients referred for orbital radiation therapy for Graves' orbitopathy from December 1st, 2001 through July 31st, 2009.

INTERVENTION

Patients received a total of 2000 cGy fractionated over 10 days.

MAIN OUTCOME MEASURES

Medical records were reviewed for: demographics, tobacco history, ocular history, history related to Graves' disease, medications, visual field tests, retinopathy, and physical exam findings. The two-tailed Student's t-test was used to determine statistically significant differences in intraocular pressure before radiation therapy and 0-3 (T1), 4-6 (T2), 7-12 (T3), and 13-18 (T4) months following radiation therapy.

RESULTS

34 eyes were available for analysis. There was no correlation between intraocular pressure and SPECS scores. Mean intraocular pressure prior to radiation therapy was 18.15 ± 3.83 mm Hg. Patients who had orbital decompression, eye muscle surgery, or glaucoma were excluded from the final analysis. There were 7, 11, 14, and 11 eyes with data at times T1, T2, T3, and T4 following radiation therapy, respectively. There was a significant decrease in mean intraocular pressure at T2, T3 and T4 of 26.00% ± 9.25%, 11.75% ± 27.58%, and 16.72% ± 13.94%, respectively.

CONCLUSIONS

There was a significant drop in mean intraocular pressure between 4 and 18 months after radiation therapy in our patient population. The mechanism by which this decrease in intraocular pressure occurs is not understood.

Thyroid eye disease

Thyroid eye disease (TED) is the most common cause of proptosis in adults, and should always be a consideration in patients with unexplained diplopia, pain, or optic nerve dysfunction. At least 80% of TED is associated with Graves disease (GD), and at least 50% of patients with GD develop clinically evident symptomatic TED. The most confusing patients for doctors of all subspecialties are the patients with eye symptoms and signs that precede serum evidence of a thyroid imbalance. Management of TED may include immunosuppressive medications, radiation, or surgery. Although the prognosis for optic nerve function is excellent, the restrictive dysmotility can result in permanent disability. Orbit and eyelid reconstruction are reserved for stable, inactive patients and are the final steps in minimizing facial alterations and enhancing the patient's daily functioning.

Radiotherapy in the treatment of Graves ophthalmopathy-to do it or not?

To the objective of this study is to evaluate the role and toxicity of radiotherapy in the treatment of Graves ophthalmopathy. In the years 2000-2003, 121 patients with malignant exophthalmos were treated with radiotherapy of the retrobulbar area to the total dose of 20 Gy in ten fractions with a 6 MeV photon beam. The treatment was performed by the team of the Clinic of Oncology of the Jagiellonian University Medical College in Cracow. The radiotherapy was preceded by intravenous steroid therapy: methylprednisolone acetate administered at the dose of 2 g/week for four consecutive weeks. The highest efficacy, expressed as improvement of all ocular symptoms, was observed for the combined treatment. Female and non-diabetic patients responded positively to the combined treatment. Radiotherapy combined with steroid therapy in the treatment of Graves ophthalmopathy seems to be an effective treatment for strictly defined indications. In the treatment of Graves-Basedow disease, radiotherapy is a well-tolerated treatment modality. Diabetes is a factor that worsens prognosis in Graves ophthalmopathy and female sex is a favourable factor for this condition.

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.

Botulinum A toxin injection for restrictive myopathy of thyroid-related orbitopathy: effects on intraocular pressure

PURPOSE

To study the effect of extraocular muscle injections of botulinum A toxin on intraocular pressure in patients with thyroid-related orbitopathy.

DESIGN

Retrospective observational case series.

METHODS

The medical records of eight consecutive patients with restrictive myopathy secondary to thyroid related orbitopathy (TRO) who underwent botulinum A toxin injection from December 1997 to December 1998 were reviewed and analyzed retrospectively. All patients were seen at the University of California, San Diego (UCSD) Thyroid Eye Center, a university-based tertiary referral center. The main outcome measure was intraocular pressure (IOP) readings taken before and after injection in both primary gaze and upgaze (involving one eye in seven of the patients and both eyes in one patient). Intraocular pressure readings were measured by an unmasked physician using a Goldmann applanation tonometer.

RESULTS

A statistically significant decrease in IOP in upgaze was noted 2 to 6 weeks following botulinum A toxin injection and in both fields of gaze (primary and upgaze) after 2 to 4 months. The mean IOP before injection was 21.4 +/- 3.0 mm Hg in primary gaze and 29.9 +/- 9.7 mm Hg in upgaze. The mean IOP, following injection at 2 to 6 weeks, was 19.2 +/- 4.2 mm Hg (P <.095) in primary gaze and 25.1 +/- 5.9 mm Hg (P <.023) in upgaze. At 2 to 4 months following injection, the mean IOP was 19.3 +/- 3.9 mm Hg (P <.044) in primary gaze and 27.7 +/- 8.5 mm Hg (P <.024) in upgaze. Six patients indicated improved ocular deviation, which was associated with a lowering of IOP. Two patients indicated no change in IOP or strabismic deviation following botulinum A toxin injection.

CONCLUSIONS

Botulinum A toxin injections cause a secondary effect to lower IOP in patients with restrictive strabismus associated with thyroid-related orbitopathy.

Retrobulbar irradiation for thyroid-associated orbitopathy: double-blind comparison between 2.4 and 16 Gy

PURPOSE

Retrobulbar irradiation is used as a standard therapy for thyroid-associated orbitopathy. The evidence of its effectiveness is, however, scarce. Doses from 2.5 to 20 Gy have been recommended.

METHODS

Forty-three patients with active thyroid-associated orbitopathy were irradiated with 2.4 Gy and 43 with 16 Gy. Five measures of outcome were used: (1) appearance of the eye region, documented with photographs; (2) Hertel exophthalmometry; (3) range of vertical eye movements; (4) eye muscle thickness (sum of three MRI sections across the eight rectus eye muscles); and (5) complaints, indicated on a visual analog scale.

RESULTS

At 3 and 6 months after irradiation, no difference between 2.4 and 16 Gy was found in any of the five outcome measures (p between 0.099 and 0.993; Kruskal-Wallis test, Holm correction). Most outcome measures were slightly, but not significantly, improved in both the 2.4 and the 16 Gy groups. Patient complaints had improved significantly in both groups and the eye muscle thickness was significantly reduced in the 2.4 Gy group after 6 months.

CONCLUSION

The lack of a difference between 2.4 and 16 Gy is compatible with four different interpretations: (1) the irradiation could be ineffective; (2) the maximal effect could be already reached at 2.4 Gy; (3) the maximal effect could lie between 2.4 and 16 Gy; and (4) the effect could increase beyond a threshold of >or=16 Gy. From general experience with inflammatory disease, the last two possibilities are unlikely; only the first two interpretations carry some probability. Although the design of the study did not allow a distinction between these two possibilities, we conclude that retrobulbar irradiation for thyroid-associated orbitopathy should not exceed 2.4 Gy.

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.

Orbital radiotherapy for Graves' ophthalmopathy

Orbital radiotherapy is a well-established method of treatment for severe Graves' ophthalmopathy, because of its anti-inflammatory and locally immunosuppressive effects. It has been used for 60 years. Conventional external x-ray and cobalt therapy have been abandoned, and most groups now use supervoltage linear accelerators (4-6 MeV). Cumulative doses may vary, but in most studies a cumulative dose of 20 Gy delivered over 2 weeks was utilized. Successful outcome depends on the selection of patients, because recent onset, active ophthalmopathy is much more favorably affected than longstanding, inactive disease. Inflammatory signs, recent onset eye muscle dysfunction, and optic neuropathy respond well to orbital radiotherapy, while proptosis and longstanding eye muscle restriction respond poorly. Overall, favorable responses have been reported, with few exceptions, in approximately 60% of cases. Combination of irradiation with high-dose systemic glucocorticoids provides better results than either treatment alone. Orbital radiotherapy is well tolerated and safe. Preexisting retinopathy (e.g., in patients with diabetes) is a contraindication to this treatment for the risk of further retinal damage. No case of radiation-induced tumors has so far been described after orbital radiotherapy for Graves' ophthalmopathy.

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.

Controversies in the clinical evaluation of active thyroid-associated orbitopathy: use of a detailed protocol with comparative photographs for objective assessment

Despite many learned publications over recent decades, the assessment of active thyroid-associated orbitopathy (TAO) remains difficult and controversial. There are no biochemical, immunological or imaging investigations which can identify active disease reliably, and clinical assessment is still of paramount importance. We therefore review the strengths and weaknesses of all methods of clinical assessment. A new atlas for clinical assessment of soft tissue signs has been developed, and its reproducibility assessed. It details a suggested protocol that could help standardize descriptions of TAO and allow more objective assessment of its activity and severity. This is relevant to general endocrinologists, who have a crucial role in the identification of patients who require ophthalmological assessment. Certain aspects are more relevant to ophthalmologists and endocrinologists who have a special clinical and research interest in TAO. Unless a reproducible system of assessment is devised and widely adopted, it will remain difficult to interpret research meaningfully, particularly if results appear to contradict.

Measuring extraocular muscle volume using dynamic contours

The effect of medical treatment on extraocular muscle enlargement in thyroid associated ophthalmopathy (TAO) may be monitored by measuring the change in volume of the extraocular muscles on serial orbital MRI examinations. In theory, 3D image sets offer the opportunity to minimise errors due to poor repositioning and partial volume effects. This study describes an automated technique for estimating extraocular muscle volumes from 3D datasets. Operator input is minimal and the technique is robust. Verification of the technique on both simulated and real datasets is described. For simulated image sets, both automated segmentation and manual outlining produced estimates of volume which were on average 4% less than "true" volume. For real patient data, extraocular muscle volumes measured by the automated technique were 1.6% (SD 13%) less than volumes measured by manual outlining. Coefficient of variation for repeat outlining of the same image dataset for the automated technique was 1.0%, compared with 4% for manual outlining. The manual technique took an experienced operator approximately 20 min to perform, compared to 7 min for the automated technique. The automated method is therefore rapid, reproducible and at least as accurate as other available methods.

Intraocular pressure changes after treatment for Graves' orbitopathy

OBJECTIVE

To evaluate the change in intraocular pressure (IOP) in subjects with Graves' orbitopathy (GO) after orbital decompression, strabismus surgery, and orbital radiation.

DESIGN

Retrospective case review.

METHODS

The charts of 172 consecutive subjects from the Neuro-ophthalmology Service at Wills Eye Hospital (Philadelphia, PA) with GO who underwent either orbital decompression, strabismus surgery, or orbital radiation between 1994 and 1999 were analyzed. Subject age, gender, diagnosis of glaucoma in either eye, use of systemic steroids or topical glaucoma medications, procedure performed, and the preoperative and postoperative IOP (in primary position and upgaze) were evaluated.

RESULTS

Of 116 eyes that underwent orbital decompression, the mean preoperative IOP was 21.6+/-4.6 mmHg (standard deviation) in primary position and 27.9+/-6.8 mmHg in upgaze. The postoperative IOP was 17.5 mmHg +/- 3.0 mmHg in primary position and 20.1+/-4.7 mmHg in upgaze, a decrease in IOP of 18.9% in primary position and 27.9% in upgaze (P<0.001). Subjects taking glaucoma medication or who had IOP greater than 21 mmHg demonstrated a significantly (P<0.001) greater reduction in IOP postoperatively. The mean preoperative IOP in the 32 subjects who had strabismus surgery was 18.5+/-2.8 mmHg (primary position), and 24.7+/-4.3 mmHg (upgaze). Postoperative IOP was 16.1 mmHg (primary position) and 16.9 mmHg (upgaze), a decrease of 2.4 mmHg (13.3%, P<0.01 in primary position) and 7.8 mmHg (31.2%, P<0.01 in upgaze). There was no statistically significant reduction in IOP after orbital radiation.

CONCLUSIONS

In the selected subgroup of subjects with GO who required intervention, orbital decompression and strabismus surgery resulted in a significant reduction in IOP in the early postoperative period, especially in subjects with preoperative IOP greater than 21 mmHg.

Evaluation of a technique for estimation of extraocular muscle volume using 2D MRI

Measurements of extraocular muscle volume may be useful as an outcome indicator in the assessment of treatment options in thyroid-associated ophthalmopathy. In this study, a technique for estimating extraocular muscle volume from two-dimensional T1 weighted MR images acquired in the coronal plane is described. For each image slice, the cross-sectional area of individual extraocular muscles was estimated using a combination of semi-automated outlining based on a local thresholding technique and manual outlining where thresholding was not possible. The technique was assessed using three sets of images: a computer-generated virtual image set with "extraocular muscles" of known volumes; a set of images from 19 biochemically and clinically euthyroid patients; and images from 7 patients with thyroid-associated ophthalmopathy. From the computer-generated images, the accuracy was determined as 7.6%. Intraobserver agreement was investigated using repeated MRI scans on a single subject and repeat outlining of muscles on five sets of images from different subjects. The mean difference between repeat measurements was 2% (SD 5.9%). We conclude that two-dimensional MR images can be used to determine changes in muscle volume of greater than 12% during treatment of thyroid-associated ophthalmopathy.

The effect of retrobulbar irradiation on exophthalmos, ductions and soft tissue signs in Graves' ophthalmopathy: a retrospective analysis of 90 cases

PURPOSE

Retrospective analysis of the effect of retrobulbar irradiation on exophthalmos, ductions and soft tissue signs in patients with Graves' ophthalmopathy.

METHODS

We analysed the charts of 111 consecutive patients who were treated with retrobulbar irradiation according to standardised intake criteria between 1992 and 1997. After exclusion of patients who underwent other treatment (with steroids or orbital decompression) shortly before or within 6 months after irradiation, and on whom insufficient data were available, 90 patients were included. For these 90 patients, we analysed the exophthalmometry, ductions, soft tissue signs and visual acuity shortly before irradiation and after 3 and 6 months, respectively.

RESULTS

In the whole group, the Hertel value was on average 22 mm (SD 2.9) both before irradiation and after 3 and 6 months of follow-up. Separate analysis of data on 25 patients with bilateral exophthalmos of more than 24 mm also revealed no change in exophthalmos at follow-up. In the whole group, both abduction and elevation had improved by about 1 degree (SD 6.6 degrees; p = 0.05) after 3 months. This improvement has little clinical significance. In a subgroup of 14 patients who showed more than 10 degrees of restricted eye motility in one or more directions, both abduction and elevation had increased by about 4 degrees (SD 10 degrees; p = 0.02) at 3 and 6 months follow-up. Soft tissue signs had improved at 6 months after irradiation. We found no change in visual acuity after irradiation.

CONCLUSION

Retrobulbar irradiation in Graves' ophthalmopathy does not seem to reduce exophthalmos. It probably improves eye motility in patients with severe restrictions. The late improvement in soft tissue signs may either be a late effect of irradiation or be related to the natural history of the disease.

Objective evaluation of improvement in optic neuropathy following radiation therapy for thyroid eye disease

PURPOSE

While the literature supports the use of radiation therapy for thyroid eye disease, it does not sufficiently describe in detail the results of radiation therapy for optic neuropathy associated with thyroid eye disease. The objective of this study is to quantify the changes in parameters of optic neuropathy after orbital irradiation for thyroid eye disease.

METHODS AND MATERIALS

Twelve consecutive patients with optic neuropathy from thyroid eye disease were followed by a single neuro-ophthalmology practice and treated by one radiation oncologist with radiation therapy from 1991 through 1995. All cases were prospectively followed for visual acuity, color vision, mean deviation, and/or foveal sensitivity and afferent pupillary defect. All patients received 2000 cGy in 10 fractions with megavoltage irradiation to the orbits.

RESULTS

Ten of 12 patients were evaluated for follow-up (one moved out of this country and one had a stroke, which confounded interpretation of examination results). An analysis was performed retrospectively while treatment and evaluation remained uniform. Five men and five women formed the basis of this study with a median age of 60 years (35-76 years). Nineteen eyes were evaluated for thyroid optic neuropathy. Improvement in optic nerve function occurred in eight of ten patients. Improvement was seen either during radiotherapy or within 2 weeks of completion. No long-term adverse effects were noted.

CONCLUSION

This study objectively demonstrates improvement in optic neuropathy from radiation therapy for thyroid eye disease.

Progressive visual loss and ophthalmoplegia

A 51-year-old woman with hyperthyroidism presented with a 4-week history of bilateral progressive visual loss despite treatment with oral prednisone. Her visual function improved after bilateral orbital decompression. The indications for and advantages and disadvantages of radiation therapy and orbital decompression in TAO are discussed. The management of intraocular pressure, strabismus, and lid abnormalities in TAO is also addressed.

Low- versus high-dose radiotherapy for Graves' ophthalmopathy: a randomized, single blind trial

Orbital radiotherapy (Rx) is a commonly used treatment for Graves' ophthalmopathy (GO), but controlled clinical trials evaluating different Rx doses and application forms have not been performed. In euthyroid patients with moderately severe GO, we randomly compared the efficacy and tolerability of three Rx protocols. Orbital Rx (telecobalt) was administered either in 20 divided fractions of 1 Gray (Gy) weekly over 20 weeks (group A) or in 10 fractions of 1 Gy (B) and 2 Gy (C) daily over 2 weeks. Before and 24 weeks after starting Rx, ophthalmic investigation and magnetic resonance imaging were performed. Response to therapy, defined as a significant amelioration of three objective parameters, was noted in 12 A (67%), 13 B (59%), and 12 C (55%) subjects (C vs. A, P = 0.007). Ophthalmic symptoms and signs regressed most in group A; changes in lid fissure width were -1.5, -0.5, and 0 mm in the A, B, and C groups, respectively (A vs. C, P = 0.005), whereas changes in intraocular pressure (upgaze) were -3, +1, and -1.5 mm Hg, respectively (A vs. B, P = 0.002). The median decreases in proptosis were -2 mm (A, P = 0.0001), -1.5 mm (B, P = 0.02), and -1 mm (C, P = 0.007; A vs. C, P = 0.0380. Visual acuity (+0.15; P = 0.02) and eye muscle motility (bulbar elevation, 30 degrees vs. 37 degrees, P = 0.03, A vs. C, P = 0.0020; abduction, 45 vs. 49 degrees, P = 0.02; A vs. C, P = 0.017) improved in group A only. A significant change in all rectus muscle areas was noted in 14 A (78%), 12 B (55%), and 9 C (41%) subjects (C vs. A, P = 0.002). A decrease in the NOSPECS classes was observed in 12 A (67%), 13 B (59%), and 13 C (59%) patients (A vs. B/C, P = 0.01). Rx-induced conjunctivitis was not observed in group A, but was seen in 4 B (18%) and 8 C (36%) subjects (C vs. A, P = 0.003). At 24 weeks, satisfaction rates were 67%, 59%, and 55% in the A, B, and C groups, respectively (C vs. A, P = 0.008). Thus, in patients with moderately severe GO, similar response rates were observed for low and high Rx doses, but the 1 Gy/week protocol was more effective and better tolerated than the short arm regimens.

Place of radiotherapy in the treatment of Graves' orbitopathy

PURPOSE

The aim of this study is to evaluate the response of Graves' orbitopathy to irradiation, and to specify the prognostic factors allowing one to better define the indications of orbital radiotherapy.

METHODS AND MATERIALS

From 1977 to 1996, 199 patients received bilateral orbital irradiation delivering 20 Gy in 10 fractions and 2 weeks for a progressive Graves' orbitopathy. 195 patients were seen between 1 and 6 months after radiotherapy. The different symptoms were studied and their response to radiation was analyzed. Factors such as age, sex, evolution of thyroid disease, history of symptoms, and previous or combined treatments were analyzed.

RESULTS

The results revealed that 50 patients (26%) had a good or excellent response, 98 (50%) had a partial response, 37 (19%) were stable, 10 (5%) had a progression of disease. The signs that best responded to radiotherapy were the infiltration of soft tissues and the corneal involvement. Responses of proptosis or oculomotor disorders were more complete when these signs were not advanced at the time of treatment. Irradiation seemed to have the same efficacy when applied as first-line treatment or after failure of corticosteroids. Neither modality of treatment of hyperthyroidism nor thyroid status at the time of orbital irradiation modified the results. The best results were recorded for early or moderately advanced presentation (p = 0.05). Patients treated within a delay of 7 months after the beginning of the ophthalmopathy had better responses than patients treated later (p = 0.10).

CONCLUSION

Radiation therapy was successful in Graves' orbitopathy by stopping the progression of disease in almost all cases, by improving the comfort of patients, by obtaining objective responses, and by avoiding surgical treatments particularly when signs were moderate.

[Endocrine orbitopathy: comparison of the long-term result and classification after radiotherapy]

BACKGROUND

This study compares 4 classifications in patients with progressive refractory Graves orbitopathy (GO) and examines their prognostic value in long-term follow-up.

PATIENTS AND METHODS

From 1984 to 1994, 60 consecutive patients (49 female, 11 male) received 20 Gy (10 x 2 Gy) radiotherapy with 6 MV Linac photons. Ocular symptoms and functional impairment was evaluated according to 4 GO-classification systems: Werner-, modified ATA- and Stanford-Score and Ophthalmopathy-Index (OI) according to Grussendorf. In addition, all patients noted their subjective response on a linear scale (0 to 100%).

RESULTS

Improvement was achieved within 1 year after radiotherapy according to the Werner-Score in 28 (47%) patients in > or = 1 symptom category, according to the modified ATA-score in 48 (80%), the Stanford-score in 47 (78%) and the OI-Score in 55 (92%) patients (reduction of > 2 points). The Werner-Score correlated less to the other scores (coefficient r < 0.5) than the other scores among themselves (r approximately 0.9). The ATA-Score improved in the different symptom categories between 47% (stage VI) and 87% (stage V). The OI-Score was reduced by a mean of 6 points. The patients reached a mean subjective improvement of +70 +/- 25%. Acute or chronic side effects were not observed. In multivariate analysis the "male gender" (p = 0.08), a "symptom duration prior to radiotherapy > 1 year" (p = 0.14) and a "high symptom category" (p = 0.11) indicated a negative prognostic trend.

CONCLUSIONS

External radiotherapy is effective for severe, progressive GO after pretreatment. A minimum follow-up of at least 12 months and standardized classification and success criteria are required.

Relationships of orbital computed tomographic findings and activity scores to the prognosis of corticosteroid therapy in patients with Graves' ophthalmopathy

To elucidate the relationships of orbital computed tomographic findings and activity scores to the prognosis of corticosteroid therapy in patients with Graves' ophthalmopathy, 22 cases were treated with corticosteroid. Orbital computed tomographic was performed before treatment and the maximal muscle areas of rectus muscle bellies were calculated from the coronal images. Activity scores were calculated according to the recommendations of an international ad hoc committee. The clinical severity of the eye disease was based on the NOSPECS classification. Observation of the effectiveness of treatment at 6 months allowed patients to be classified into good responders or poor responders. Twelve of 22 patients (54.5%) belonged to the good responders. The total muscle areas were less in good responders. Although the total muscle areas were significantly correlated with the activity scores, no difference in the activity scores was noted between these two groups. We concluded that although activity score seems to be a predictor of initial responsiveness to anti-inflammatory drugs, the maximal muscle area is a prognostic factor of corticosteroid therapy in patients with Graves' ophthalmopathy.

Clinical features of Graves' ophthalmopathy in an incidence cohort

PURPOSE

To determine the clinical characteristics of an incidence cohort of patients with Graves' ophthalmopathy.

METHODS

We reviewed the community medical records of 120 patients residing in Olmsted County, Minnesota, in whom Graves' ophthalmopathy was diagnosed between 1976 and 1990.

RESULTS

Among 120 patients with Graves' ophthalmopathy, 108 (90%) patients had Graves' hyperthyroidism, one (1%) had primary hypothyroidism, four (3%) had Hashimoto's thyroiditis, and seven (6%) were euthyroid. At some point in their clinical course, eyelid retraction was present in 108 patients, whereas the approximate frequency of exophthalmos was 62% (73 patients); restrictive extraocular myopathy, 43% (51 patients); and optic nerve dysfunction, 6% (seven patients). Only six (5%) patients had eyelid retraction, exophthalmos, optic nerve dysfunction, extraocular muscle involvement, and hyperthyroidism. At the time of diagnosis of ophthalmopathy, upper eyelid retraction and eyelid lag were documented in 85 and 52 patients, respectively, and the most frequent ocular symptom was pain (36 patients, 30%). Diplopia was noted at the initial examination by 20 patients, lacrimation was present in 25 patients, 19 patients had photophobia, and nine patients had blurred vision. Decreased vision from optic neuropathy was present in less than 2% of eyes at the time of diagnosis. Thyroid dermopathy and acropachy accompanied Graves' ophthalmopathy in five patients (4%) and one (1%) patient, respectively. Myasthenia gravis occurred in only one patient.

CONCLUSIONS

Eyelid retraction is the most common clinical sign of Graves' ophthalmopathy. The complete constellation of typical features (hyperthyroidism, eyelid retraction, exophthalmos, restrictive extraocular myopathy, and optic nerve dysfunction) occurs relatively infrequently.

The treatment of Graves' ophthalmopathy in an incidence cohort

PURPOSE

To determine the frequencies of medical and surgical treatments in an incidence cohort of 120 patients with Graves' ophthalmopathy.

METHODS

We reviewed the community medical records and administered a follow-up questionnaire.

RESULTS

Of the 120 patients, 89 (74.2%) required either no therapy or only supportive measures. Six patients (5.0%) were treated with systemic corticosteroids. One patient had orbital radiotherapy. Twenty-four patients (20.0%) underwent one or more surgical procedures. The cumulative probabilities of undergoing ophthalmic surgery of any type were 5.0% by one year after the diagnosis of ophthalmopathy, 9.3% after two years, 15.9% after five years, and 21.8% after ten years. The need for surgery was significantly related to age (P < .01; Cox proportional hazards model) but was not significantly dependent on gender (P = .5) or the interaction of age and gender (P = .15). The overall risk of the need for surgery was 2.6 times greater in patients older than 50 years (95% confidence interval, 1.2 to 5.8) than in younger patients. There were no significant differences between tobacco smokers and nonsmokers in the cumulative probabilities of undergoing surgery.

CONCLUSION

In 24 (20%) patients, one or more surgical procedures were used to treat Graves' ophthalmopathy. The probability of surgical intervention was significantly related to patient age (older than 50 years), but it was not related to gender or smoking.

Fundus manifestations of orbital disease and treatment of orbital disease

Disorders of the orbit can secondarily involve the eye. Although nonspecific, changes which can be noted on funduscopic examination including abnormalities of the retina, choroid, and optic nerve, can be secondary to an underlying orbital process. Awareness of these findings and their association with orbital disease is of great importance to the practicing ophthalmologist, since many orbital disorders are treatable and indeed, some are life-threatening. In addition, treatment of these disorders can potentially result in a variety of ocular complications. An understanding of the potential risks is of the utmost importance in planning treatment of an orbital disease.

Echographic monitoring of response of extraocular muscles to irradiation in Graves' ophthalmopathy

PURPOSE

Confirmation of the efficacy of orbital irradiation in Graves' ophthalmopathy is needed due to the unpredictable natural history of the disease, the variation in individual clinical presentations, the contribution of other simultaneous treatments, and the lack of controlled studies using objective criteria to classify and assess response over time. Orbital echography before and at select intervals following orbital irradiation is proposed as an objective parameter of tissue response to orbital irradiation over time.

METHODS AND MATERIALS

From January, 1983 to September, 1993, 55 patients with progressive Graves' ophthalmopathy underwent 20 Gy retrobulbar irradiation. On retrospective review, standardized orbital echography was performed randomly prior to irradiation in 37 of the 55 patients to assess the acoustic characteristics of the extraocular muscles and to quantitate their individual and summed diameters. Twenty-one patients had at least one follow-up echographic evaluation at random intervals of 0 to 27.5 months following completion of irradiation. Twelve patients received steroids before or during irradiation, which were tapered in proximity to completion of radiation. Follow-up ranged from 2 to 65 months with the majority followed at least 6 months (18 patients).

RESULTS

Of the 21 patients with serial studies, 18 showed an interval decrease in individual and summed muscle size over time and return of symmetry. Interval improvement was documented as early as the 1 month follow-up study, with continued improvement seen during the 3-9-month studies, with stability typically achieved within 12 months. One patient had further changes between the 21 and 27.5 month follow-up studies. Exacerbation of disease was, however, echographically demonstrated in three patients at 6.5, 8.5, and 13 months. Follow-up studies in two of these patients again revealed improvement, one following tapered steroids. The third patient required orbital decompression.

CONCLUSION

Objective parameters of response are needed to document both the immediate and long-term outcome of orbital irradiation on the course of Graves' ophthalmopathy and confirm its efficacy. Serial echography is proposed as a new technique for providing parameters to judge response.